Provider Demographics
NPI:1801893326
Name:GOMEZ, JOSE FERNANDO (MD)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:FERNANDO
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11781 LEE JACKSON MEMORIAL HIGHWAY
Mailing Address - Street 2:SUITE 550
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-3309
Mailing Address - Country:US
Mailing Address - Phone:703-295-9360
Mailing Address - Fax:703-766-9725
Practice Address - Street 1:703 MAIN STREET
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07503
Practice Address - Country:US
Practice Address - Phone:973-754-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06515500207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7187203Medicaid
NJ683549Medicare PIN
NJ7187203Medicaid