1134671290 NPI number — DR. MARTIN GOMEZ M.D.

Table of content: DR. MARTIN GOMEZ M.D. (NPI 1134671290)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134671290 NPI number — DR. MARTIN GOMEZ M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOMEZ
Provider First Name:
MARTIN
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1134671290
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/15/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9761 NW 28TH TER
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DORAL
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33172-1339
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-790-5673
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2750 W 68TH ST STE 127
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HIALEAH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33016-5449
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-558-0765
Provider Business Practice Location Address Fax Number:
305-558-0768
Provider Enumeration Date:
10/25/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  19902 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 390200000X , with the licence number: 14316-I , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X , with the licence number: ACN1098 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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