Healthcare Provider Details

I. General information

NPI: 1912991878
Provider Name (Legal Business Name): ELLIS E GOMEZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 01/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 LAWN AVE
BUFFALO NY
14207-1816
US

IV. Provider business mailing address

155 LAWN AVE
BUFFALO NY
14207-1816
US

V. Phone/Fax

Practice location:
  • Phone: 716-875-2904
  • Fax: 716-875-6717
Mailing address:
  • Phone: 716-875-2904
  • Fax: 716-875-6717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1935561
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: