Basic Information
| Provider Information | |||||||||
| NPI: | 1942738240 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUTIERREZ | ||||||||
| FirstName: | EZARA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 11130 CHRISTUS HILLS | ||||||||
| Address2: | MEDICAL PLAZA 3, 3RD FLOOR | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782513585 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2107039001 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11130 CHRISTUS HLS FL | ||||||||
| Address2: | MEDICAL PLAZA 3, 3RD FLOOR | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2107039001 | ||||||||
| FaxNumber: | 2107039155 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2017 | ||||||||
| LastUpdateDate: | 11/07/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | BP10061 | TX | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.