Provider Demographics
NPI:1073012191
Name:GOMEZ CAMPO, LIZARDO
Entity Type:Individual
Prefix:
First Name:LIZARDO
Middle Name:
Last Name:GOMEZ CAMPO
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 1:3633 NW 9TH ST APT 8
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33125-3860
Mailing Address - Country:US
Mailing Address - Phone:971-940-0673
Mailing Address - Fax:
Practice Address - Street 1:3633 NW 9TH ST APT 8
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33125-3860
Practice Address - Country:US
Practice Address - Phone:971-940-0673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-04
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician