Healthcare Provider Details

I. General information

NPI: 1952064321
Provider Name (Legal Business Name): MR. MARIO ERNESTO GOMEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2021
Last Update Date: 03/27/2023
Certification Date: 03/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43-08 52ND STREET, 2ND FLOOR
WOODSIDE NY
11377
US

IV. Provider business mailing address

129 W 31ST ST
NEW YORK NY
10001-3403
US

V. Phone/Fax

Practice location:
  • Phone: 718-458-4243
  • Fax:
Mailing address:
  • Phone: 984-227-4600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number119231
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: