Provider Demographics
NPI:1952041717
Name:MORAN GOMEZ, GUILLERMO DANIEL (MDMG)
Entity Type:Individual
Prefix:
First Name:GUILLERMO
Middle Name:DANIEL
Last Name:MORAN GOMEZ
Suffix:
Gender:M
Credentials:MDMG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1398
Mailing Address - Street 2:
Mailing Address - City:JUNCOS
Mailing Address - State:PR
Mailing Address - Zip Code:00777-1398
Mailing Address - Country:US
Mailing Address - Phone:787-595-6655
Mailing Address - Fax:
Practice Address - Street 1:URB VILLA BORINQUEN
Practice Address - Street 2:CALLE NITAINO G-37
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725
Practice Address - Country:US
Practice Address - Phone:787-595-6655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-30
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4980116343900000X, 347C00000X, 341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No347C00000XTransportation ServicesPrivate Vehicle
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR90909Medicaid