Provider Demographics
NPI:1518905884
Name:GOMEZ, MARIO H (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:H
Last Name:GOMEZ
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:PO BOX 5567
Mailing Address - Street 2:5918 HARBOR PARK DRIVE
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-0027
Mailing Address - Country:US
Mailing Address - Phone:804-353-0010
Mailing Address - Fax:804-353-0041
Practice Address - Street 1:5918 HARBOUR PARK DR
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-2163
Practice Address - Country:US
Practice Address - Phone:804-353-0010
Practice Address - Fax:804-353-0041
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010425242084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004945557Medicaid
VA007172966Medicaid
VA451731OtherANTHEM - GCH LOC
VA451731OtherHEALTHKEEPERS - GCH LOC
VAO89172OtherSENTARA
VA381732OtherANTHEM - POWH LOC
VA381732OtherHEALTHEKEEPERS - POWH LOC
VA267418OtherMAMSI
VA036579003OtherMAGELLAN
VAA932442OtherVALUE OPTIONS
VA381732OtherHEALTHEKEEPERS - POWH LOC
VA267418OtherMAMSI
VA260001589Medicare ID - Type UnspecifiedHMG INDIV. NUMBER
VAC03563Medicare ID - Type UnspecifiedHMG GROUP NUMBER