Provider Demographics
NPI:1750546404
Name:GOMEZ, RIO MARTIN YAP (IDC)
Entity type:Individual
Prefix:
First Name:RIO MARTIN
Middle Name:YAP
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5800 QUANTRELL AVE APT 420
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22312-2710
Mailing Address - Country:US
Mailing Address - Phone:917-658-8744
Mailing Address - Fax:
Practice Address - Street 1:5800 QUANTRELL AVE #420
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22132
Practice Address - Country:US
Practice Address - Phone:917-658-8744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-22
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1710I1002X1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman