Provider Demographics
NPI:1467613356
Name:GOMEZ-TROCHEZ, MAXIMILIAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MAXIMILIAN
Middle Name:
Last Name:GOMEZ-TROCHEZ
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 1:365 MAIN ST STE 201
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06795-2249
Mailing Address - Country:US
Mailing Address - Phone:860-274-2418
Mailing Address - Fax:860-274-2986
Practice Address - Street 1:365 MAIN ST STE 201
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:CT
Practice Address - Zip Code:06795-2249
Practice Address - Country:US
Practice Address - Phone:860-274-2418
Practice Address - Fax:860-274-2986
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-23
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT049979207R00000X
CT49979207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTP01040202OtherRAILROAD MEDICARE
CT5856125OtherCIGNA
CT05856125OtherGREAT WEST
CT1154493OtherUSA
CT717021/627772OtherWELLCARE
CTP4376817OtherOXFORD
CT049979OtherCONNECTICARE
CT717021/627772OtherWELLCARE