Healthcare Provider Details

I. General information

NPI: 1083708457
Provider Name (Legal Business Name): JAMIE GOMEZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8200 CONSTITUTION PL NE STE A PMG KASEMAN FAMILY HEALTHCARE
ALBUQUERQUE NM
87110-7647
US

IV. Provider business mailing address

PO BOX 26666 PHS PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-291-2402
  • Fax: 505-291-2599
Mailing address:
  • Phone: 505-923-5356
  • Fax: 505-923-5354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number9945
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: