Provider Demographics
NPI:1598096679
Name:SAN MARTIN GOMEZ, MARIO (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:
Last Name:SAN MARTIN 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 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-424-3123
Mailing Address - Fax:239-424-4041
Practice Address - Street 1:636 DEL PRADO BLVD S
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-2668
Practice Address - Country:US
Practice Address - Phone:239-424-3123
Practice Address - Fax:239-424-4041
Is Sole Proprietor?:No
Enumeration Date:2010-01-28
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI70462207R00000X, 208M00000X
MI4301097702207R00000X, 208M00000X
FLME157634208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100141906Medicaid