Healthcare Provider Details

I. General information

NPI: 1366431835
Provider Name (Legal Business Name): ENEIDA GOMEZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 08/05/2020
Certification Date: 08/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 TREE BLVD STE 5
ST AUGUSTINE FL
32084-5715
US

IV. Provider business mailing address

PO BOX 3123
SAINT AUGUSTINE FL
32085-3123
US

V. Phone/Fax

Practice location:
  • Phone: 904-342-0672
  • Fax: 904-342-0673
Mailing address:
  • Phone: 904-824-4990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME83444
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: