Provider Demographics
NPI:1568410835
Name:GOMEZ, ANGEL R (MD)
Entity Type:Individual
Prefix:
First Name:ANGEL
Middle Name:R
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 1:325 E BASELINE RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85042-6510
Mailing Address - Country:US
Mailing Address - Phone:602-824-4352
Mailing Address - Fax:602-824-4259
Practice Address - Street 1:325 E BASELINE RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-6510
Practice Address - Country:US
Practice Address - Phone:602-824-4352
Practice Address - Fax:602-824-4259
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ29250207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0206250OtherBLUE CROSS/BLUE SHIELD
AZ584533Medicaid
AZAZ0206250OtherBLUE CROSS/BLUE SHIELD
AZ584533Medicaid