Provider Demographics
NPI:1881143055
Name:GOMEZ, JORGE
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1834 W ARROW RTE 65
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4205
Mailing Address - Country:US
Mailing Address - Phone:909-717-6954
Mailing Address - Fax:323-890-9700
Practice Address - Street 1:5835 S EASTERN AVE
Practice Address - Street 2:
Practice Address - City:COMMERCE
Practice Address - State:CA
Practice Address - Zip Code:90040-4029
Practice Address - Country:US
Practice Address - Phone:323-725-4644
Practice Address - Fax:323-890-9700
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-28
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program