Provider Demographics
NPI:1093915936
Name:GOMEZ, MIGUEL A (LND)
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:A
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:LND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 1 BOX 6801
Mailing Address - Street 2:
Mailing Address - City:GUAYAMA
Mailing Address - State:PR
Mailing Address - Zip Code:00784-9608
Mailing Address - Country:US
Mailing Address - Phone:787-864-4300
Mailing Address - Fax:
Practice Address - Street 1:URB. LA HACIENDA
Practice Address - Street 2:HECR - SUITE # 108
Practice Address - City:GUAYAMA
Practice Address - State:PR
Practice Address - Zip Code:00785
Practice Address - Country:US
Practice Address - Phone:787-686-0062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-19
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR973133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR57173Medicare PIN