Provider Demographics
NPI:1184224230
Name:LOPEZ GOMEZ, GUSTAVO HERNAN
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:HERNAN
Last Name:LOPEZ GOMEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:581 OCEAN PKWY APT 8D
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11218-5961
Mailing Address - Country:US
Mailing Address - Phone:813-447-0053
Mailing Address - Fax:
Practice Address - Street 1:760 BROADWAY RM 2C319
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206-5317
Practice Address - Country:US
Practice Address - Phone:718-963-8310
Practice Address - Fax:718-630-3244
Is Sole Proprietor?:No
Enumeration Date:2020-10-28
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program