Provider Demographics
NPI:1053674572
Name:GOMEZ, DEMARIS
Entity Type:Individual
Prefix:
First Name:DEMARIS
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DEMARIS
Other - Middle Name:
Other - Last Name:SANTOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:369 E 148TH ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10455-4041
Mailing Address - Country:US
Mailing Address - Phone:718-769-2698
Mailing Address - Fax:
Practice Address - Street 1:369 E 148TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10455-4041
Practice Address - Country:US
Practice Address - Phone:718-769-2698
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1704349174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY174400000XOtherSERVICE PROVIDER