Provider Demographics
NPI:1356791669
Name:GOMEZ, VIVIANA ANDREA
Entity type:Individual
Prefix:
First Name:VIVIANA
Middle Name:ANDREA
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 1:315 OVINGTON AVE APT 5A
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-1422
Mailing Address - Country:US
Mailing Address - Phone:646-373-1020
Mailing Address - Fax:
Practice Address - Street 1:336 W 37TH ST
Practice Address - Street 2:SUITE 880
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10018-4212
Practice Address - Country:US
Practice Address - Phone:212-226-7965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-16
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY800149298174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist