Provider Demographics
NPI:1508810383
Name:GOMEZ, MINVERVA
Entity Type:Individual
Prefix:DR
First Name:MINVERVA
Middle Name:
Last Name:GOMEZ
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 1:14020 COIT RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75240-3706
Mailing Address - Country:US
Mailing Address - Phone:214-570-0703
Mailing Address - Fax:
Practice Address - Street 1:14020 COIT RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-3706
Practice Address - Country:US
Practice Address - Phone:214-570-0703
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH3677207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
00890QMedicare ID - Type Unspecified
TXE10931Medicare UPIN