Provider Demographics
NPI:1902197064
Name:GOMEZ VACA, LUIS ALBERTO (MD)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:ALBERTO
Last Name:GOMEZ VACA
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 1:1107 MEMORIAL DR STE 201
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-8662
Mailing Address - Country:US
Mailing Address - Phone:706-277-7311
Mailing Address - Fax:706-272-3512
Practice Address - Street 1:1107 MEMORIAL DR STE 201
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-8662
Practice Address - Country:US
Practice Address - Phone:706-277-7311
Practice Address - Fax:706-272-3512
Is Sole Proprietor?:No
Enumeration Date:2011-04-25
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA71695207N00000X
IN11016108A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine