Healthcare Provider Details

I. General information

NPI: 1316357346
Provider Name (Legal Business Name): CODY RYON GOMEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2014
Last Update Date: 02/01/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 S AUSTIN AVE SUITE 205
GEORGETOWN TX
78626-7545
US

IV. Provider business mailing address

3614 CORNERSTONE ST
ROUND ROCK TX
78681-3709
US

V. Phone/Fax

Practice location:
  • Phone: 512-763-4060
  • Fax:
Mailing address:
  • Phone: 830-857-4730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberR6012
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: