Provider Demographics
NPI:1437451333
Name:JACK GUTMAN DO PROFESSIONAL CORP
Entity type:Organization
Organization Name:JACK GUTMAN DO PROFESSIONAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:H
Authorized Official - Last Name:GUTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:714-998-3627
Mailing Address - Street 1:6200 E CANYON RIM RD
Mailing Address - Street 2:STE 105B
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92807-4317
Mailing Address - Country:US
Mailing Address - Phone:714-998-3627
Mailing Address - Fax:714-998-1895
Practice Address - Street 1:6200 E CANYON RIM RD
Practice Address - Street 2:STE 105B
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92807-4317
Practice Address - Country:US
Practice Address - Phone:714-998-3627
Practice Address - Fax:714-998-1895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-28
Last Update Date:2010-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A4188261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care