Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208100000X | Physical Medicine & Rehabilitation Doctor | L3943 | TX |
N | 225400000X | Rehabilitation Practitioner | L3943 | TX |
NPI | 1063413482 |
---|---|
Provider Name | Mr. Omar Alberto Colon Gutierrez |
First Address | Irving, TX 75063-7514 |
Second Address | Plano, TX 75075-7526 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/08/2005 |
Last Update Date | 12/03/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
8V3207 | BCBS (01) | |
H71993 | (02) | |
L3943 | LICENSE NUMBER (01) | TX |