Provider Demographics
NPI:1265733539
Name:GOMEZ, MARK I
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:I
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1117 STRAKA TER
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73139-2518
Mailing Address - Country:US
Mailing Address - Phone:918-360-9926
Mailing Address - Fax:
Practice Address - Street 1:105365 HIGHWAY102
Practice Address - Street 2:
Practice Address - City:MCLOUD
Practice Address - State:OK
Practice Address - Zip Code:74851
Practice Address - Country:US
Practice Address - Phone:405-964-2081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-03
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health