Healthcare Provider Details

I. General information

NPI: 1669485199
Provider Name (Legal Business Name): JAMES N GOMEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 03/06/2023
Certification Date: 03/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5885 KINGSTOWNE BLVD
ALEXANDRIA VA
22315-5702
US

IV. Provider business mailing address

5885 KINGSTOWNE BLVD
ALEXANDRIA VA
22315-5702
US

V. Phone/Fax

Practice location:
  • Phone: 703-842-0248
  • Fax:
Mailing address:
  • Phone: 703-842-0248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOP1000265
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618000627
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTPOP123
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1566
License Number StateNE
# 5
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3737-35
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: