Provider Demographics
NPI:1083927297
Name:GOMEZ, GUSTAVO ADOLFO (MD)
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:ADOLFO
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 1:145 W 23RD ST STE 101
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16502-2858
Mailing Address - Country:US
Mailing Address - Phone:814-452-2767
Mailing Address - Fax:814-459-2976
Practice Address - Street 1:145 W 23RD ST STE 101
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16502-2858
Practice Address - Country:US
Practice Address - Phone:814-452-2767
Practice Address - Fax:814-459-2976
Is Sole Proprietor?:No
Enumeration Date:2010-07-16
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD456612207RG0100X
IL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program