Provider Demographics
NPI:1659414241
Name:GOMEZ, DANIEL I
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:I
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 1:45-3380 MAMANE ST UNIT 4
Mailing Address - Street 2:
Mailing Address - City:HONOKAA
Mailing Address - State:HI
Mailing Address - Zip Code:96727-6933
Mailing Address - Country:US
Mailing Address - Phone:808-640-1141
Mailing Address - Fax:808-775-8834
Practice Address - Street 1:45-3380 MAMANE ST UNIT 4
Practice Address - Street 2:
Practice Address - City:HONOKAA
Practice Address - State:HI
Practice Address - Zip Code:96727-6933
Practice Address - Country:US
Practice Address - Phone:808-640-1141
Practice Address - Fax:808-775-8834
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI539372-19Medicaid