Provider Demographics
NPI:1134671290
Name:GOMEZ, MARTIN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:
Last Name:GOMEZ
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 1:9761 NW 28TH TER
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33172-1339
Mailing Address - Country:US
Mailing Address - Phone:305-790-5673
Mailing Address - Fax:
Practice Address - Street 1:2750 W 68TH ST STE 127
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-5449
Practice Address - Country:US
Practice Address - Phone:305-558-0765
Practice Address - Fax:305-558-0768
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-25
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR19902208D00000X
PR14316-I390200000X
FLACN1098208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty