Provider Demographics
NPI:1487629010
Name:GOMEZ, MIGUEL JOSE (MD)
Entity Type:Individual
Prefix:DR
First Name:MIGUEL
Middle Name:JOSE
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MIGUEL
Other - Middle Name:JOSE
Other - Last Name:GOMEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 37174
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-3174
Mailing Address - Country:US
Mailing Address - Phone:571-423-5699
Mailing Address - Fax:571-423-5698
Practice Address - Street 1:3300 GALLOWS RD
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22042-3300
Practice Address - Country:US
Practice Address - Phone:703-776-4001
Practice Address - Fax:703-776-7113
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-17
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101228416174400000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006209009Medicaid