Provider Demographics
NPI:1053971259
Name:GUTIERREZ, JORGE (DO)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:GUTIERREZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 CHAPEL ST APT 508
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-3176
Mailing Address - Country:US
Mailing Address - Phone:973-986-2499
Mailing Address - Fax:
Practice Address - Street 1:652 BOSTON POST RD STE 1
Practice Address - Street 2:
Practice Address - City:GUILFORD
Practice Address - State:CT
Practice Address - Zip Code:06437-2748
Practice Address - Country:US
Practice Address - Phone:203-453-0677
Practice Address - Fax:203-458-7015
Is Sole Proprietor?:No
Enumeration Date:2019-06-19
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT75422207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program