Provider Demographics
NPI:1295797645
Name:GOMEZ, ILDEFONSO (MD)
Entity type:Individual
Prefix:DR
First Name:ILDEFONSO
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6101 BLUE LAGOON DR STE 200
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-3168
Mailing Address - Country:US
Mailing Address - Phone:305-500-2000
Mailing Address - Fax:305-500-2145
Practice Address - Street 1:7101 W MCNAB RD STE 101
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33321-5351
Practice Address - Country:US
Practice Address - Phone:954-722-5600
Practice Address - Fax:855-252-2845
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 90272207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU56452Medicare ID - Type Unspecified
FLI38747Medicare UPIN