=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316571912
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARITIN DE PENA GOMEZ MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/24/2020
-----------------------------------------------------
Last Update Date | 01/09/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 601 PROFESSIONAL DR STE 220
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30046-7649
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-709-6922
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 601A PROFESSIONAL DR SUITE 220
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30046
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-709-6922
-----------------------------------------------------
Fax | 770-709-6910
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 21702
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 100027
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------