Provider Demographics
NPI:1083303317
Name:GOMEZ, ALBERTO (OD)
Entity Type:Individual
Prefix:
First Name:ALBERTO
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12900 S OLD US HWY 27 STE 7
Mailing Address - Street 2:
Mailing Address - City:DEWITT
Mailing Address - State:MI
Mailing Address - Zip Code:48820-8340
Mailing Address - Country:US
Mailing Address - Phone:517-669-4411
Mailing Address - Fax:
Practice Address - Street 1:12900 S OLD US HWY 27 STE 7
Practice Address - Street 2:
Practice Address - City:DEWITT
Practice Address - State:MI
Practice Address - Zip Code:48820-8340
Practice Address - Country:US
Practice Address - Phone:517-669-4411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-03
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI390200000X
MI4901005696152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program