Provider Demographics
NPI:1851933170
Name:GOMEZ VARGAS, ANDRES EDUARDO (SA-C)
Entity Type:Individual
Prefix:
First Name:ANDRES
Middle Name:EDUARDO
Last Name:GOMEZ VARGAS
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:ANDRES
Other - Middle Name:EDUARDO
Other - Last Name:GOMEZ VARGAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SA-C
Mailing Address - Street 1:PO BOX 2550
Mailing Address - Street 2:
Mailing Address - City:ROWLETT
Mailing Address - State:TX
Mailing Address - Zip Code:75030-2550
Mailing Address - Country:US
Mailing Address - Phone:214-227-2457
Mailing Address - Fax:214-764-0880
Practice Address - Street 1:2230 LINE DR
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-2602
Practice Address - Country:US
Practice Address - Phone:786-553-6073
Practice Address - Fax:678-585-1136
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-09
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA19-413246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant