Provider Demographics
NPI:1134325822
Name:SERGIO R. GOMEZ M.D. INC
Entity Type:Organization
Organization Name:SERGIO R. GOMEZ M.D. INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SERGIO
Authorized Official - Middle Name:RENE
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-868-1620
Mailing Address - Street 1:2005 N GAREY AVE
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-2721
Mailing Address - Country:US
Mailing Address - Phone:909-868-1620
Mailing Address - Fax:909-593-4500
Practice Address - Street 1:2005 NORTH GAREY AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767
Practice Address - Country:US
Practice Address - Phone:909-868-1620
Practice Address - Fax:909-593-4500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-21
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA74276207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A742760Medicaid
CAW19156Medicare ID - Type Unspecified
CAH68743Medicare UPIN