Provider Demographics
NPI:1548756356
Name:GOMEZ, GUSTAVO JR
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:
Last Name:GOMEZ
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:336 W 21ST ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33010-2519
Mailing Address - Country:US
Mailing Address - Phone:786-291-6005
Mailing Address - Fax:
Practice Address - Street 1:336 W 21ST ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33010-2519
Practice Address - Country:US
Practice Address - Phone:786-291-6005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-04
Last Update Date:2018-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician