Provider Demographics
NPI:1821021957
Name:GOMEZ, KELLY ALLAN (DPM)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ALLAN
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 N 500 W
Mailing Address - Street 2:SUITE 103
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601
Mailing Address - Country:US
Mailing Address - Phone:801-375-6677
Mailing Address - Fax:801-375-0346
Practice Address - Street 1:777 N 500 W
Practice Address - Street 2:SUITE 103
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601
Practice Address - Country:US
Practice Address - Phone:801-375-6677
Practice Address - Fax:801-375-0346
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT367951213ES0103X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000064004OtherMEDICARE PTAN #
4385650001Medicare NSC
U75122Medicare UPIN
000012169Medicare PIN