Provider Demographics
NPI:1467211557
Name:GOMARA, JESSCA
Entity Type:Individual
Prefix:
First Name:JESSCA
Middle Name:
Last Name:GOMARA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12401 W OKEECHOBEE RD LOT 299
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33018-2938
Mailing Address - Country:US
Mailing Address - Phone:786-931-6702
Mailing Address - Fax:
Practice Address - Street 1:12401 W OKEECHOBEE RD LOT 299
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33018-2938
Practice Address - Country:US
Practice Address - Phone:786-931-6702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2085U0001X2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound