Provider Demographics
NPI:1093766156
Name:GOMEZ, LUIS L (MD)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:L
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-3057
Mailing Address - Country:US
Mailing Address - Phone:814-336-6068
Mailing Address - Fax:814-337-0198
Practice Address - Street 1:505 POPLAR ST
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-3057
Practice Address - Country:US
Practice Address - Phone:814-336-6068
Practice Address - Fax:814-337-0198
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-13
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD018911Y207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAGO43342OtherHIGHMARK NUMBER
PAB96728Medicare UPIN