Healthcare Provider Details

I. General information

NPI: 1700308913
Provider Name (Legal Business Name): JOSE SANCHEZ GOMEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2017
Last Update Date: 01/02/2025
Certification Date: 01/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 HENRY LUCKOW LN
BELVIDERE IL
61008-1702
US

IV. Provider business mailing address

PO BOX 78866
MILWAUKEE WI
53278-8866
US

V. Phone/Fax

Practice location:
  • Phone: 779-696-8650
  • Fax: 815-544-4691
Mailing address:
  • Phone: 779-696-7150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-153617
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number125-070965
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: