Healthcare Provider Details

I. General information

NPI: 1134671290
Provider Name (Legal Business Name): MARTIN GOMEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2016
Last Update Date: 10/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2750 W 68TH ST STE 127
HIALEAH FL
33016-5449
US

IV. Provider business mailing address

9761 NW 28TH TER
DORAL FL
33172-1339
US

V. Phone/Fax

Practice location:
  • Phone: 305-558-0765
  • Fax: 305-558-0768
Mailing address:
  • Phone: 305-790-5673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number19902
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number14316-I
License Number StatePR
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberACN1098
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: