Provider Demographics
NPI:1538458153
Name:MARIO GOMEZ MD PA
Entity Type:Organization
Organization Name:MARIO GOMEZ MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:786-256-4174
Mailing Address - Street 1:8775 SW 164 ST
Mailing Address - Street 2:
Mailing Address - City:PALMETTO BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-3562
Mailing Address - Country:US
Mailing Address - Phone:786-256-4174
Mailing Address - Fax:
Practice Address - Street 1:925 NE 30TH TER
Practice Address - Street 2:SUITE 300
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33033-7613
Practice Address - Country:US
Practice Address - Phone:786-256-4174
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-05
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME102113207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001046400Medicaid
FLBW677ZMedicare PIN