Healthcare Provider Details

I. General information

NPI: 1174880603
Provider Name (Legal Business Name): DANNY J GOMEZ D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2012
Last Update Date: 01/07/2021
Certification Date: 01/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 ROUTE 17
RIDGEWOOD NJ
07450-2010
US

IV. Provider business mailing address

331 BOULEVARD
GLEN ROCK NJ
07452-3212
US

V. Phone/Fax

Practice location:
  • Phone: 201-445-2288
  • Fax: 201-445-2288
Mailing address:
  • Phone: 973-202-4933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number25MD00319300
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number006626
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: