Provider Demographics
NPI:1578947750
Name:GOMEZ LOPEZ, TATIANA FLAMINIA
Entity Type:Individual
Prefix:
First Name:TATIANA
Middle Name:FLAMINIA
Last Name:GOMEZ LOPEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 ASTORIA BLVD APT 1G
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11102-5208
Mailing Address - Country:US
Mailing Address - Phone:347-517-6245
Mailing Address - Fax:
Practice Address - Street 1:10211 ROOSEVELT AVE # 4
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368
Practice Address - Country:US
Practice Address - Phone:718-898-1386
Practice Address - Fax:718-898-1093
Is Sole Proprietor?:No
Enumeration Date:2015-07-16
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY296659207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program