Provider Demographics
NPI:1659551828
Name:GOMEZ, LUIS MICHEAL (COTA)
Entity Type:Individual
Prefix:MR
First Name:LUIS
Middle Name:MICHEAL
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 W 143RD ST
Mailing Address - Street 2:1A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10030-1203
Mailing Address - Country:US
Mailing Address - Phone:646-773-3832
Mailing Address - Fax:
Practice Address - Street 1:313 W 143RD ST
Practice Address - Street 2:1A
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10030-1203
Practice Address - Country:US
Practice Address - Phone:646-773-3832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-05
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003940-1172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker