Provider Demographics
NPI:1639483936
Name:GOMEZ, EFREN ALEJANDRO (OD)
Entity Type:Individual
Prefix:DR
First Name:EFREN
Middle Name:ALEJANDRO
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1703 CALUMET AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:WHITING
Mailing Address - State:IN
Mailing Address - Zip Code:46394-1414
Mailing Address - Country:US
Mailing Address - Phone:219-659-1105
Mailing Address - Fax:
Practice Address - Street 1:1703 CALUMET AVE
Practice Address - Street 2:SUITE B
Practice Address - City:WHITING
Practice Address - State:IN
Practice Address - Zip Code:46394-1414
Practice Address - Country:US
Practice Address - Phone:219-659-1105
Practice Address - Fax:219-659-4855
Is Sole Proprietor?:No
Enumeration Date:2010-07-29
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003645A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201012650Medicaid
INM400023823Medicare PIN