Healthcare Provider Details

I. General information

NPI: 1841619418
Provider Name (Legal Business Name): ANDREW THOMAS GOMEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2014
Last Update Date: 12/07/2024
Certification Date: 12/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 112TH AVE NE STE D258
BELLEVUE WA
98004-3727
US

IV. Provider business mailing address

PO BOX 25608
SALT LAKE CITY UT
84125-0608
US

V. Phone/Fax

Practice location:
  • Phone: 425-498-2272
  • Fax: 425-498-2334
Mailing address:
  • Phone: 206-320-4476
  • Fax: 206-568-7043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberML 60478159
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number25MA10430800
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberMD60768420
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: