Provider Demographics
NPI:1982097200
Name:GOMEZ, JORGE LUIS
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:LUIS
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 1:4540 SW 152ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-3360
Mailing Address - Country:US
Mailing Address - Phone:305-450-5712
Mailing Address - Fax:
Practice Address - Street 1:1380 N KROME AVE
Practice Address - Street 2:SUITE #110
Practice Address - City:FLORIDA CITY
Practice Address - State:FL
Practice Address - Zip Code:33034-2406
Practice Address - Country:US
Practice Address - Phone:305-247-4464
Practice Address - Fax:305-247-4546
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-11
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT16763225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist