Provider Demographics
NPI:1801445663
Name:GOMEZ, BENJAMIN JACOB (IDC)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:JACOB
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 1:2001 VICTOR WHARF
Mailing Address - Street 2:
Mailing Address - City:PEARL CITY
Mailing Address - State:HI
Mailing Address - Zip Code:96782
Mailing Address - Country:US
Mailing Address - Phone:954-614-7005
Mailing Address - Fax:
Practice Address - Street 1:2001 VICTOR WHARF
Practice Address - Street 2:
Practice Address - City:PEARL CITY
Practice Address - State:HI
Practice Address - Zip Code:96782
Practice Address - Country:US
Practice Address - Phone:954-614-7005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-05
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty CorpsmanGroup - Multi-Specialty
No171000000XOther Service ProvidersMilitary Health Care Provider
No1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical TechniciansGroup - Multi-Specialty
No261QM1102XAmbulatory Health Care FacilitiesClinic/CenterMilitary Outpatient Operational (Transportable) Component
No261QM1103XAmbulatory Health Care FacilitiesClinic/CenterMilitary Ambulatory Procedure Visits Operational (Transportable)
No286500000XHospitalsMilitary HospitalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1384550807OtherDOD ID