Provider Demographics
NPI:1245743764
Name:GOMEZ, RAUL ANTONIO
Entity Type:Individual
Prefix:
First Name:RAUL
Middle Name:ANTONIO
Last Name: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 1:1349 SW 74TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144-5347
Mailing Address - Country:US
Mailing Address - Phone:786-325-6296
Mailing Address - Fax:
Practice Address - Street 1:1349 SW 74TH CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144-5347
Practice Address - Country:US
Practice Address - Phone:786-325-6296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-06
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician