Provider Demographics
NPI:1508354010
Name:GOMEZ BAUTISTA, JOSE (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:
Last Name:GOMEZ BAUTISTA
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 1:1829 W 25TH CT
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99337-3613
Mailing Address - Country:US
Mailing Address - Phone:509-579-9141
Mailing Address - Fax:
Practice Address - Street 1:624 E FRONT AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-2139
Practice Address - Country:US
Practice Address - Phone:509-626-9900
Practice Address - Fax:509-626-9917
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-30
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAMD61127903207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program