Provider Demographics
NPI:1215395074
Name:GOMEZ, ROBERTO ALEXIS (ATC, LAT)
Entity Type:Individual
Prefix:MR
First Name:ROBERTO
Middle Name:ALEXIS
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15065 SW 31ST TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33185-4941
Mailing Address - Country:US
Mailing Address - Phone:786-514-7181
Mailing Address - Fax:
Practice Address - Street 1:5000 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33146-2008
Practice Address - Country:US
Practice Address - Phone:786-308-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-08
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL44332255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAL4433OtherATHLETIC TRAINER