Healthcare Provider Details

I. General information

NPI: 1841293636
Provider Name (Legal Business Name): MANUEL ANTONIO GOMEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 01/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 W MAIN ST
WHITE SULPHUR SPRINGS WV
24986-2414
US

IV. Provider business mailing address

PO BOX 130
MAXWELTON WV
24957-0130
US

V. Phone/Fax

Practice location:
  • Phone: 304-647-6061
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License Number10506
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number10506
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: