Provider Demographics
NPI:1215030630
Name:GOMEZ LOPEZ, WANDA Y (MD)
Entity Type:Individual
Prefix:DR
First Name:WANDA
Middle Name:Y
Last Name:GOMEZ LOPEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:WANDA
Other - Middle Name:Y
Other - Last Name:GOMEZ LOPEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:121 S ORANGE AVE STE 940
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32801-3234
Mailing Address - Country:US
Mailing Address - Phone:407-658-9687
Mailing Address - Fax:407-286-4515
Practice Address - Street 1:910 W VINE ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4165
Practice Address - Country:US
Practice Address - Phone:407-517-9582
Practice Address - Fax:407-978-6644
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN1011208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFG6400066OtherDEA CERTIFICATE