Provider Demographics
NPI:1780611731
Name:GOMEZ, MIQUEL DEAN II (MD)
Entity type:Individual
Prefix:
First Name:MIQUEL
Middle Name:DEAN
Last Name:GOMEZ
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MIKE
Other - Middle Name:DEAN
Other - Last Name:GOMEZ
Other - Suffix:II
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:10150 N 67TH AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85302-1004
Mailing Address - Country:US
Mailing Address - Phone:623-561-4547
Mailing Address - Fax:623-412-4995
Practice Address - Street 1:10150 N 67TH AVE STE 101
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302-1004
Practice Address - Country:US
Practice Address - Phone:623-561-4547
Practice Address - Fax:623-412-4995
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ23411207RP1001X
AZ23411207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ324244Medicaid
AZG45806Medicare UPIN
AZ324244Medicaid
AZZ144084Medicare PIN