Provider Demographics
NPI:1124021795
Name:CHARLESTON, GOMEZ (MD)
Entity Type:Individual
Prefix:
First Name:GOMEZ
Middle Name:
Last Name:CHARLESTON
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 1:9000 S STONY ISLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-3508
Mailing Address - Country:US
Mailing Address - Phone:773-731-0670
Mailing Address - Fax:
Practice Address - Street 1:9000 S STONY ISLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-3508
Practice Address - Country:US
Practice Address - Phone:773-731-0670
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC42300Medicare UPIN
IL206555Medicare ID - Type Unspecified