Healthcare Provider Details

I. General information

NPI: 1912973207
Provider Name (Legal Business Name): EDMUND GOMEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 12/17/2021
Certification Date: 12/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 RONALD REAGAN PKWY SUITE 266
AVON IN
46123-6910
US

IV. Provider business mailing address

250 N SHADELAND AVE
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-209-2000
  • Fax: 317-209-2010
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number01038627A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: