Provider Demographics
NPI:1790703957
Name:GOMEZ, ENRIQUE (MD)
Entity Type:Individual
Prefix:
First Name:ENRIQUE
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 1:8585 SW 72ND ST STE 109
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-3746
Mailing Address - Country:US
Mailing Address - Phone:305-274-3393
Mailing Address - Fax:305-274-3493
Practice Address - Street 1:8585 SW 72ND ST STE 109
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-3746
Practice Address - Country:US
Practice Address - Phone:305-274-3393
Practice Address - Fax:305-274-3493
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2018-04-25
Deactivation Date:2016-03-21
Deactivation Code:
Reactivation Date:2016-04-07
Provider Licenses
StateLicense IDTaxonomies
FLME25725208D00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL258666500Medicaid
FL92777Medicare ID - Type Unspecified
FL258666500Medicaid