Provider Demographics
NPI:1093930802
Name:GOMILLION, EDWARD JOHAN (LMT)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:JOHAN
Last Name:GOMILLION
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3227 E BELL RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-2700
Mailing Address - Country:US
Mailing Address - Phone:602-485-8434
Mailing Address - Fax:
Practice Address - Street 1:3227 E BELL RD
Practice Address - Street 2:SUITE 201
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-2700
Practice Address - Country:US
Practice Address - Phone:602-485-8434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT04378P174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist