Healthcare Provider Details

I. General information

NPI: 1851933170
Provider Name (Legal Business Name): ANDRES EDUARDO GOMEZ VARGAS SA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: ANDRES EDUARDO GOMEZ VARGAS SA-C

II. Dates (important events)

Enumeration Date: 10/09/2019
Last Update Date: 04/05/2022
Certification Date: 04/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2230 LINE DR
LAWRENCEVILLE GA
30043-2602
US

IV. Provider business mailing address

PO BOX 2550
ROWLETT TX
75030-2550
US

V. Phone/Fax

Practice location:
  • Phone: 786-553-6073
  • Fax: 678-585-1136
Mailing address:
  • Phone: 214-227-2457
  • Fax: 214-764-0880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number19-413
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: