Provider Demographics
NPI:1629162540
Name:GOMEZ, HECOTR JOSE (MD)
Entity Type:Individual
Prefix:DR
First Name:HECOTR
Middle Name:JOSE
Last Name: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 148670
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-8670
Mailing Address - Country:US
Mailing Address - Phone:773-577-3458
Mailing Address - Fax:630-858-2335
Practice Address - Street 1:850 W IRVING PARK ROAD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613
Practice Address - Country:US
Practice Address - Phone:773-577-3458
Practice Address - Fax:630-858-2335
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
720572Medicare ID - Type Unspecified
D15345Medicare UPIN