Provider Demographics
NPI:1316201312
Name:GOMEZ RAMIREZ, MAURICIO (MD)
Entity Type:Individual
Prefix:DR
First Name:MAURICIO
Middle Name:
Last Name:GOMEZ RAMIREZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 505164
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5164
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:1319 S LANDRUM ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:MO
Practice Address - Zip Code:65712-1910
Practice Address - Country:US
Practice Address - Phone:417-466-2001
Practice Address - Fax:417-466-2005
Is Sole Proprietor?:No
Enumeration Date:2012-06-25
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2015021625207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1316201312Medicaid
MO1316201312Medicaid