Provider Demographics
NPI:1518625045
Name:OCAMPO GOMEZ, FERNANDO (SUDPT)
Entity Type:Individual
Prefix:
First Name:FERNANDO
Middle Name:
Last Name:OCAMPO GOMEZ
Suffix:
Gender:M
Credentials:SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7801 GREENWOOD AVE N APT 401
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-4638
Mailing Address - Country:US
Mailing Address - Phone:720-459-2956
Mailing Address - Fax:
Practice Address - Street 1:515 3RD AVE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-2304
Practice Address - Country:US
Practice Address - Phone:206-464-1570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-01
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61217809390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program