Provider Demographics
NPI:1003169400
Name:GOMEZ DE MELLO, JULIO A
Entity Type:Individual
Prefix:MR
First Name:JULIO
Middle Name:A
Last Name:GOMEZ DE MELLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:928 W 67TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-6467
Mailing Address - Country:US
Mailing Address - Phone:305-965-6098
Mailing Address - Fax:
Practice Address - Street 1:928 W 67TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-6467
Practice Address - Country:US
Practice Address - Phone:305-965-6098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-23
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA-64739174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty