Healthcare Provider Details

I. General information

NPI: 1700792181
Provider Name (Legal Business Name): MATTHEW GOMEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 S PACIFIC AVE
SAN PEDRO CA
90731-2656
US

IV. Provider business mailing address

1331 W 227TH ST
TORRANCE CA
90501-5007
US

V. Phone/Fax

Practice location:
  • Phone: 310-519-8723
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: