Healthcare Provider Details

I. General information

NPI: 1083927297
Provider Name (Legal Business Name): GUSTAVO ADOLFO GOMEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2010
Last Update Date: 10/02/2020
Certification Date: 10/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 W 23RD ST STE 101
ERIE PA
16502-2858
US

IV. Provider business mailing address

145 W 23RD ST STE 101
ERIE PA
16502-2858
US

V. Phone/Fax

Practice location:
  • Phone: 814-452-2767
  • Fax: 814-459-2976
Mailing address:
  • Phone: 814-452-2767
  • Fax: 814-459-2976

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberMD456612
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: