=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467613356
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAXIMILIAN GOMEZ-TROCHEZ M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2008
-----------------------------------------------------
Last Update Date | 04/29/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 365 MAIN ST STE 201
-----------------------------------------------------
City | WATERTOWN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06795-2249
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-274-2418
-----------------------------------------------------
Fax | 860-274-2986
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 365 MAIN ST STE 201
-----------------------------------------------------
City | WATERTOWN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06795-2249
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-274-2418
-----------------------------------------------------
Fax | 860-274-2986
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 049979
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 49979
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------