Provider Demographics
NPI:1023040243
Name:GOMEZ, DOMINGO (MD)
Entity Type:Individual
Prefix:DR
First Name:DOMINGO
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 W 49TH ST STE 1
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-3637
Mailing Address - Country:US
Mailing Address - Phone:305-364-3404
Mailing Address - Fax:305-364-3433
Practice Address - Street 1:415 W 49TH ST STE 1
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-3637
Practice Address - Country:US
Practice Address - Phone:305-364-3404
Practice Address - Fax:305-364-3433
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0029637207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL255666900Medicaid
FLD63291Medicare UPIN
FL255666900Medicaid