Provider Demographics
NPI:1568443356
Name:GOMEZ, JORGE (MD)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:
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 1:1355 SOUTH INTERNATIONAL PARKWAY
Mailing Address - Street 2:SUITE 1451
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-1694
Mailing Address - Country:US
Mailing Address - Phone:407-333-9888
Mailing Address - Fax:407-333-9444
Practice Address - Street 1:1355 SOUTH INTERNATIONAL PARKWAY
Practice Address - Street 2:SUITE 1451
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-1694
Practice Address - Country:US
Practice Address - Phone:407-333-9888
Practice Address - Fax:407-333-9444
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-08
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0015929207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL049702900Medicaid
112886230OtherZR MED
FL59062Medicare PIN
D64551Medicare UPIN