Provider Demographics
NPI:1235792888
Name:GOLEZ, JEROME MAMARIL
Entity Type:Individual
Prefix:MR
First Name:JEROME
Middle Name:MAMARIL
Last Name:GOLEZ
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 1:9701 SYDNEY MARILYN LN
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78748-3086
Mailing Address - Country:US
Mailing Address - Phone:954-292-2777
Mailing Address - Fax:
Practice Address - Street 1:1224 CORVADURA ST
Practice Address - Street 2:
Practice Address - City:GRAHAM
Practice Address - State:TX
Practice Address - Zip Code:76450-4355
Practice Address - Country:US
Practice Address - Phone:817-304-5652
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-18
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1298587225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist