1306092812 NPI number — KELLY A GOMEZ DPM PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306092812 NPI number — KELLY A GOMEZ DPM PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KELLY A GOMEZ DPM PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ROCKY MOUNTAIN FOOT AND ANKLE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306092812
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/02/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
777 N 500 W
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
PROVO
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84601-1541
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-375-6677
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
777 N 500 W
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
PROVO
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84601-1541
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-375-6677
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/15/2008

Additional Information

Authorized Official

Authorized Official Last Name:
GOMEZ
Authorized Official First Name:
KELLY
Authorized Official Middle Name:
ALLAN
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
801-375-6677

Provider Taxonomy Codes

  • Taxonomy code: 261QP1100X , with the licence number:  367951 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com