Provider Demographics
NPI:1912973207
Name:GOMEZ, EDMUND (MD)
Entity Type:Individual
Prefix:DR
First Name:EDMUND
Middle Name:
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1115 RONALD REAGAN PKWY
Practice Address - Street 2:SUITE 266
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-6910
Practice Address - Country:US
Practice Address - Phone:317-209-2000
Practice Address - Fax:317-209-2010
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01038627A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100218170Medicaid
INP01575974OtherRAILROAD MEDICARE
IN677690LLMedicare PIN
IN160042631Medicare PIN
IN264430279Medicare PIN
INP01575974OtherRAILROAD MEDICARE