Provider Demographics
NPI:1700573821
Name:GOMEZ, IVAN (MD, MS)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:MD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-7834
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:120 MAIN ST
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-7834
Practice Address - Country:US
Practice Address - Phone:346-907-8809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-19
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17005738212084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty