Provider Demographics
NPI:1336183862
Name:GOMEZ, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1603 REVERE DRIVE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22308
Mailing Address - Country:US
Mailing Address - Phone:301-351-1727
Mailing Address - Fax:
Practice Address - Street 1:1150 VARNUM ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017-2104
Practice Address - Country:US
Practice Address - Phone:202-854-7074
Practice Address - Fax:202-854-7470
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0061518174400000X, 208000000X
MDD615182080N0001X
DCMD0429572080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No174400000XOther Service ProvidersSpecialist
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD0020737Medicaid
WV3810013613Medicaid