Provider Demographics
NPI:1376808667
Name:MASSEY-GOMEZ, SMITA (MD)
Entity Type:Individual
Prefix:
First Name:SMITA
Middle Name:
Last Name:MASSEY-GOMEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 COX RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-9263
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:281-428-7035
Practice Address - Street 1:995 HOSPITALITY WAY
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:MD
Practice Address - Zip Code:21001-1755
Practice Address - Country:US
Practice Address - Phone:410-306-7880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-12
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0084071207R00000X, 207R00000X
TXQ5484207R00000X
MA252905207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX461364YMVQMedicare PIN
TX461364ZSWDMedicare PIN
TX8FM139OtherBLUE CROSS BLUE SHIELD
TX352767301Medicaid
TX8FT362OtherBLUE CROSS BLUE SHIELD
TXP01643111OtherRR MEDICARE
TX352767302Medicaid