Healthcare Provider Details

I. General information

NPI: 1124984372
Provider Name (Legal Business Name): LUIS ALBERTO GOMEZ JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/31/2025
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8330 RESEDA BLVD
NORTHRIDGE CA
91324-4619
US

IV. Provider business mailing address

8330 RESEDA BLVD
NORTHRIDGE CA
91324-4619
US

V. Phone/Fax

Practice location:
  • Phone: 818-996-1051
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-IQVTSP
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: