Provider Demographics
NPI:1598331662
Name:GOMEZ, JUAN CARLOS
Entity Type:Individual
Prefix:MR
First Name:JUAN
Middle Name:CARLOS
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1455 W 75TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33014-3813
Mailing Address - Country:US
Mailing Address - Phone:786-258-1291
Mailing Address - Fax:954-824-2440
Practice Address - Street 1:1455 W 75TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33014-3813
Practice Address - Country:US
Practice Address - Phone:786-637-4111
Practice Address - Fax:954-824-2440
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-31
Last Update Date:2021-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12044146L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic