Provider Demographics
NPI:1780613687
Name:DOMINGO GOMEZ MD PA
Entity type:Organization
Organization Name:DOMINGO GOMEZ MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DOMINGO
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-364-3404
Mailing Address - Street 1:415 W 49TH ST
Mailing Address - Street 2:A
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-3637
Mailing Address - Country:US
Mailing Address - Phone:305-364-3404
Mailing Address - Fax:305-364-3433
Practice Address - Street 1:415 W 49TH ST
Practice Address - Street 2:A
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-3637
Practice Address - Country:US
Practice Address - Phone:305-364-3404
Practice Address - Fax:305-364-3433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0029637261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL255666900Medicaid
FL255666900Medicaid
FL95001Medicare ID - Type Unspecified