Individual
ILITCH DIAZ GUTIERREZ
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1655 BEAM AVE STE 302, MAPLEWOOD, MN 55109-1477
(651) 227-6351
Mailing address
3144 CHOWEN AVE S, APT 219B, MINNEAPOLIS, MN 55416-5398
(505) 818-7180
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
RS2009-0378
NM
208G00000X
Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
Primary
63088
MN
Other
Enumeration date
07/29/2009
Last updated
08/30/2018
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