Provider Demographics
NPI:1508887597
Name:GOMOKE, JANICE M (PT)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:M
Last Name:GOMOKE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 69030
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-9030
Mailing Address - Country:US
Mailing Address - Phone:757-873-2302
Mailing Address - Fax:757-873-2306
Practice Address - Street 1:4020 RAINTREE RD STE D
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23321-3749
Practice Address - Country:US
Practice Address - Phone:757-484-4241
Practice Address - Fax:757-484-4487
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305002436225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1508887597Medicaid
VA010208793Medicaid
VAP00233936OtherMEDICARE RR
VA192941OtherBCBS (PHYSICAL THERAPY)
VA7899071OtherAETNA
VAP00871013OtherMEDICARE RAILROAD
VA192941OtherBCBS (PHYSICAL THERAPY)
VA007921O04Medicare PIN
VAP00871013OtherMEDICARE RAILROAD