Provider Demographics
NPI:1598190878
Name:GOMEZ, JONATHAN CHRISTIAN (IDMT)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:CHRISTIAN
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4311 CARSWELL AVE
Mailing Address - Street 2:BLDG 340
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89191-7069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2444 CASSIDY RD
Practice Address - Street 2:
Practice Address - City:FORT BLISS
Practice Address - State:TX
Practice Address - Zip Code:79916-3500
Practice Address - Country:US
Practice Address - Phone:915-568-8755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-05
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians