1841636842 NPI number — LAURA GOMEZ OTR

Table of content: LAURA GOMEZ OTR (NPI 1841636842)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841636842 NPI number — LAURA GOMEZ OTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOMEZ
Provider First Name:
LAURA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTR
Provider Gender Code:
F

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:
1841636842
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/08/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
870 CONREID DR NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT CHARLOTTE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33952-9715
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
786-280-9104
Provider Business Mailing Address Fax Number:
786-401-6211

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
870 CONREID DR NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT CHARLOTTE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33952-9715
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
786-280-9104
Provider Business Practice Location Address Fax Number:
786-401-6211
Provider Enumeration Date:
05/16/2013

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: 225X00000X , with the licence number:  OT15622 , 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)

  • Identifier: 119542500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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