Provider Demographics
NPI:1013080415
Name:CHAVEZ-GOMEZ, CONSUELO ELIZABETH (OD)
Entity Type:Individual
Prefix:DR
First Name:CONSUELO
Middle Name:ELIZABETH
Last Name:CHAVEZ-GOMEZ
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7508 37TH AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-6538
Mailing Address - Country:US
Mailing Address - Phone:718-476-1458
Mailing Address - Fax:718-476-1462
Practice Address - Street 1:7508 37TH AVE
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-6538
Practice Address - Country:US
Practice Address - Phone:718-476-1458
Practice Address - Fax:718-476-1462
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT006194152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY922825OtherBLOCK
NYNY6871OtherEYEMED
NY02042368Medicaid
NY3101581OtherUNITED HEALTHCARE
NYT006194OtherMETROPLUS
NY52743OtherDAVIS
NYOV27627OtherSPECTERA
NYG400007695Medicare PIN
NYT006194OtherMETROPLUS