Provider Demographics
NPI:1578553079
Name:GOMEZ, JUAN R (MD)
Entity Type:Individual
Prefix:DR
First Name:JUAN
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:PO BOX 1198
Mailing Address - Street 2:
Mailing Address - City:LAS PIEDRAS
Mailing Address - State:PR
Mailing Address - Zip Code:00771-1198
Mailing Address - Country:US
Mailing Address - Phone:787-893-5030
Mailing Address - Fax:787-893-3922
Practice Address - Street 1:URB VILLA HILDA
Practice Address - Street 2:CALLE 1 A5
Practice Address - City:YABUCOA
Practice Address - State:PR
Practice Address - Zip Code:00767
Practice Address - Country:US
Practice Address - Phone:787-893-5030
Practice Address - Fax:787-893-3922
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-26
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6337207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C79696Medicare UPIN
PR27763Medicare ID - Type Unspecified