Healthcare Provider Details

I. General information

NPI: 1134669963
Provider Name (Legal Business Name): MENCIA M GOMEZ MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2017
Last Update Date: 06/06/2024
Certification Date: 06/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1946 TYLER ST
HOLLYWOOD FL
33020-4517
US

IV. Provider business mailing address

1946 TYLER ST
HOLLYWOOD FL
33020-4517
US

V. Phone/Fax

Practice location:
  • Phone: 754-333-9815
  • Fax: 571-386-2627
Mailing address:
  • Phone: 754-333-9815
  • Fax: 571-386-2627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME121955
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. MENCIA M GOMEZ
Title or Position: PRESIDENT
Credential: MD
Phone: 754-333-9815