Provider Demographics
NPI:1952882169
Name:BOSCH GOMEZ, MARA (SA-C)
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:
Last Name:BOSCH GOMEZ
Suffix:
Gender:F
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13661 NW 10TH LN
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33182-2633
Mailing Address - Country:US
Mailing Address - Phone:786-657-6728
Mailing Address - Fax:
Practice Address - Street 1:13661 NW 10TH LN
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33182-2633
Practice Address - Country:US
Practice Address - Phone:786-657-6728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-25
Last Update Date:2018-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18-364246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant