Provider Demographics
NPI:1548417405
Name:GOMEZ MORAYTA, ENRIQUE (MD)
Entity Type:Individual
Prefix:
First Name:ENRIQUE
Middle Name:
Last Name:GOMEZ MORAYTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ENRIQUE
Other - Middle Name:
Other - Last Name:MORAYTA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:800 SW 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1902
Mailing Address - Country:US
Mailing Address - Phone:503-221-0161
Mailing Address - Fax:
Practice Address - Street 1:9250 SW HALL BLVD
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-6721
Practice Address - Country:US
Practice Address - Phone:503-293-0161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ44281207R00000X
ORMD165430207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
324199OtherAMERICAN BOARD OF INTERNAL MEDICINE CERTIFIED
324199OtherAMERICAN BOARD OF INTERNAL MEDICINE CERTIFIED
AZ637272Medicaid