Provider Demographics
NPI:1720196801
Name:GOMEZ, JAVIER (RDN, CDE)
Entity Type:Individual
Prefix:
First Name:JAVIER
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:RDN, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11414 E SQUASH BLOSSOM LOOP
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85747-6219
Mailing Address - Country:US
Mailing Address - Phone:520-904-0889
Mailing Address - Fax:
Practice Address - Street 1:1100 E AJO WAY STE 212
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85713
Practice Address - Country:US
Practice Address - Phone:520-904-0889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-28
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT06671133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered