1972508752 NPI number — GUILLERMO GOMEZ NP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972508752 NPI number — GUILLERMO GOMEZ NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOMEZ
Provider First Name:
GUILLERMO
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972508752
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/26/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
165 VICTORIA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELLENWOOD
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30294-2854
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-598-2158
Provider Business Mailing Address Fax Number:
404-361-2427

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4146 JONESBORO RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FOREST PARK
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30297-1038
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-361-2469
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/17/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  RN126015 NP , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 810457223B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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