Provider Demographics
NPI:1043284375
Name:GOMEZ-DIAZ, SUZANNE M (MD)
Entity Type:Individual
Prefix:DR
First Name:SUZANNE
Middle Name:M
Last Name:GOMEZ-DIAZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SUZANNE
Other - Middle Name:MICHELLE
Other - Last Name:GOMEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:818 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:95601
Mailing Address - Country:US
Mailing Address - Phone:903-236-8600
Mailing Address - Fax:903-236-8600
Practice Address - Street 1:818 N 4TH ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:95601
Practice Address - Country:US
Practice Address - Phone:903-236-8600
Practice Address - Fax:903-236-8605
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2017-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA73474208000000X
TXL4954208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX153840702Medicaid
TX153840701Medicaid
H65503Medicare UPIN
TX153840701Medicaid