Healthcare Provider Details

I. General information

NPI: 1306888540
Provider Name (Legal Business Name): JORGE E GOMEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 12/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6701 FANNIN ST 1710.00
HOUSTON TX
77030-2608
US

IV. Provider business mailing address

6701 FANNIN ST 1710.00
HOUSTON TX
77030-2608
US

V. Phone/Fax

Practice location:
  • Phone: 832-822-3633
  • Fax: 832-825-3689
Mailing address:
  • Phone: 832-822-3633
  • Fax: 832-825-3689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License NumberH5237
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: