Provider Demographics
NPI:1477606366
Name:GOMEZ, MICHAEL ALEXANDER (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ALEXANDER
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1447 NW 156TH AVE
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33028-1665
Mailing Address - Country:US
Mailing Address - Phone:954-430-9564
Mailing Address - Fax:
Practice Address - Street 1:1770 W 32ND PL
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-4512
Practice Address - Country:US
Practice Address - Phone:305-885-4477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2020-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 3891152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101685200Medicaid
FL1477606366Medicaid