Healthcare Provider Details

I. General information

NPI: 1174963045
Provider Name (Legal Business Name): ABRAHAM ISAIAS GOMEZ HERNANDEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2013
Last Update Date: 06/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29201 TELEGRAPH RD STE 324
SOUTHFIELD MI
48034-1331
US

IV. Provider business mailing address

29201 TELEGRAPH RD STE 324
SOUTHFIELD MI
48034-1331
US

V. Phone/Fax

Practice location:
  • Phone: 248-357-5100
  • Fax: 248-357-2548
Mailing address:
  • Phone: 248-357-5100
  • Fax: 248-357-2548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: