Provider Demographics
NPI:1295184497
Name:GOMEZ, OSCAR ANGEL
Entity Type:Individual
Prefix:
First Name:OSCAR
Middle Name:ANGEL
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 1:22828 W. MOUL RD.
Mailing Address - Street 2:
Mailing Address - City:ELMWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:61529
Mailing Address - Country:US
Mailing Address - Phone:309-634-5235
Mailing Address - Fax:
Practice Address - Street 1:5220 BELFORT RD. SUIT 130
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256
Practice Address - Country:US
Practice Address - Phone:904-446-3760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-08
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.013348364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist