Provider Demographics
NPI:1164832903
Name:GOMEZ, ALBERTO (MD)
Entity Type:Individual
Prefix:
First Name:ALBERTO
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 1:609 W MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72764-5335
Mailing Address - Country:US
Mailing Address - Phone:479-234-6280
Mailing Address - Fax:
Practice Address - Street 1:609 W MAPLE AVE
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-5335
Practice Address - Country:US
Practice Address - Phone:479-751-5711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-01
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023000705207P00000X, 207Q00000X
390200000X
LA306789207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200076359Medicaid
MO26D0446923OtherCLIA (TCMH)