Provider Demographics
NPI:1598092447
Name:GOMEZ, DENISSE
Entity Type:Individual
Prefix:MISS
First Name:DENISSE
Middle Name:
Last Name:GOMEZ
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 1:4268 IRIS AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-1251
Mailing Address - Country:US
Mailing Address - Phone:817-919-3919
Mailing Address - Fax:
Practice Address - Street 1:2400 JACKSBORO HWY
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76114-2201
Practice Address - Country:US
Practice Address - Phone:817-427-9353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-13
Last Update Date:2009-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX48085183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist