MEDICARE: DR. MIKEL RAY GOMEZ M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	MD00014506	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G05688	OTHER	WA	REGENCE
2	16802	OTHER	WA	L&I
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1427122050
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MIKEL RAY GOMEZ M.D.

Provider Business Mailing Address
First Line	:	5438 140TH AVE SW
Second Line	:
City	:	ROCHESTER
State	:	WA
Zip	:	98579-9712
Country	:	US
Telephone Number	:	360-754-8852
Fax Number	:	360-357-4590

Provider Business Practice Location Address
First Line	:	405 BLACK HILLS LN SW STE F
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98502-8661
Country	:	US
Telephone Number	:	360-357-4778
Fax Number	:	360-357-4590

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/17/2006
Last Update Date	:	07/08/2007

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