Provider Demographics
NPI:1386647394
Name:GOMEZ, REYNALDO OCAMPO (MD)
Entity Type:Individual
Prefix:
First Name:REYNALDO
Middle Name:OCAMPO
Last Name:GOMEZ
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 1:74998 COUNTRY CLUB DR
Mailing Address - Street 2:SUITE 220, PMB 183
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92260-1970
Mailing Address - Country:US
Mailing Address - Phone:760-416-3770
Mailing Address - Fax:760-320-8551
Practice Address - Street 1:1180 N INDIAN CANYON DR
Practice Address - Street 2:STE W300
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-4809
Practice Address - Country:US
Practice Address - Phone:760-416-3770
Practice Address - Fax:760-320-8551
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-23
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA51395174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF51011Medicare UPIN