Healthcare Provider Details

I. General information

NPI: 1609225853
Provider Name (Legal Business Name): ANDRES ALONSO GOMEZ GARZA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2016
Last Update Date: 10/22/2020
Certification Date: 10/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4050 BEYER BLVD
SAN YSIDRO CA
92173-2007
US

IV. Provider business mailing address

1601 PRECISION PARK LN
SAN DIEGO CA
92173-1345
US

V. Phone/Fax

Practice location:
  • Phone: 619-662-4100
  • Fax:
Mailing address:
  • Phone: 858-336-1253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number163427
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: