Provider Demographics
NPI:1912991878
Name:GOMEZ, ELLIS E (MD)
Entity Type:Individual
Prefix:
First Name:ELLIS
Middle Name:E
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 LAWN AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14207-1816
Mailing Address - Country:US
Mailing Address - Phone:716-875-2904
Mailing Address - Fax:716-875-6717
Practice Address - Street 1:155 LAWN AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14207-1816
Practice Address - Country:US
Practice Address - Phone:716-875-2904
Practice Address - Fax:716-875-6717
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1935561207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01446551Medicaid
NY01446551Medicaid
NY14205EMedicare ID - Type Unspecified