Provider Demographics
NPI:1780004622
Name:GOMEZ, OLIVER
Entity Type:Individual
Prefix:
First Name:OLIVER
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 1:141 E MAIN ST
Mailing Address - Street 2:4TH FLOOR ADMINISTRATION
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06702-2310
Mailing Address - Country:US
Mailing Address - Phone:203-574-9000
Mailing Address - Fax:203-574-9006
Practice Address - Street 1:26 NORTH ELM ST.
Practice Address - Street 2:MORRIS RECOVERY HOUSE
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06702-1701
Practice Address - Country:US
Practice Address - Phone:203-574-3986
Practice Address - Fax:203-597-5459
Is Sole Proprietor?:No
Enumeration Date:2014-04-18
Last Update Date:2014-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker