Healthcare Provider Details

I. General information

NPI: 1801445663
Provider Name (Legal Business Name): BENJAMIN JACOB GOMEZ IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2019
Last Update Date: 12/17/2019
Certification Date: 12/17/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 VICTOR WHARF
PEARL CITY HI
96782
US

IV. Provider business mailing address

2001 VICTOR WHARF
PEARL CITY HI
96782
US

V. Phone/Fax

Practice location:
  • Phone: 954-614-7005
  • Fax:
Mailing address:
  • Phone: 954-614-7005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM1102X
TaxonomyMilitary Outpatient Operational (Transportable) Component Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM1103X
TaxonomyMilitary Ambulatory Procedure Visits Operational (Transportable) Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: