Healthcare Provider Details

I. General information

NPI: 1497515977
Provider Name (Legal Business Name): ESTEPHANIA CANDELO GOMEZ MD, MSC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2024
Last Update Date: 06/18/2024
Certification Date: 06/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CL. 18 #122-135, BARRIO PANCE TOWE L WORK
CALI VALLE DEL CAUCA
760003
CO

IV. Provider business mailing address

CL. 18 #122-135, BARRIO PANCE TOWE L WORK
CALI VALLE DEL CAUCA
760003
CO

V. Phone/Fax

Practice location:
  • Phone: 692-555-2334
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number10982478
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: