Provider Demographics
NPI:1689931032
Name:GOMEZ, VICTOR
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:
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 1:11601 PELLICANO DR
Mailing Address - Street 2:SUITE B8
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-6279
Mailing Address - Country:US
Mailing Address - Phone:915-593-3556
Mailing Address - Fax:915-595-6556
Practice Address - Street 1:11601 PELLICANO DR
Practice Address - Street 2:SUITE B8
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-6279
Practice Address - Country:US
Practice Address - Phone:915-593-3556
Practice Address - Fax:915-595-6556
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-23
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0055163332B00000X, 332BP3500X, 332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
531034OtherBLUE CROSS BLUE SHIELD TX
TX144537101Medicaid
TX144538901Medicaid
TXQMP000003931980OtherMOLINA HEALTH CARE
531034OtherBLUE CROSS BLUE SHIELD TX