Provider Demographics
NPI:1699031088
Name:GOMEZ, GUSTAVO (MD)
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:
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 1:1957 COOPER FOSTER PARK RD
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:OH
Mailing Address - Zip Code:44001-1207
Mailing Address - Country:US
Mailing Address - Phone:440-989-3801
Mailing Address - Fax:
Practice Address - Street 1:105 OPPORTUNITY WAY
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:OH
Practice Address - Zip Code:44050-9018
Practice Address - Country:US
Practice Address - Phone:440-222-4160
Practice Address - Fax:440-355-4213
Is Sole Proprietor?:No
Enumeration Date:2012-04-10
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.128395207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0179466Medicaid