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General NPI Number Information
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NPI Number | 1801445663
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Entity Type | Individual
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Provider Name | BENJAMIN JACOB GOMEZ IDC
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Gender | Male
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Dates
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Enumeration Date | 09/05/2019
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Last Update Date | 12/17/2019
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Provider Practice Location Address
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Address Line | 2001 VICTOR WHARF
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City | PEARL CITY
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State | HI
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Zip | 96782
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Country | US
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Telephone | 954-614-7005
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Fax |
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Provider Business Mailing Address
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Address Line | 2001 VICTOR WHARF
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City | PEARL CITY
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State | HI
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Zip | 96782
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Country | US
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Telephone | 954-614-7005
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171000000X
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Taxonomy Name | Military Health Care Provider
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1710I1003X
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Taxonomy Name | Independent Duty Medical Technicians
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QM1102X
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Taxonomy Name | Military Outpatient Operational (Transportable) Component Clinic/Center
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 261QM1103X
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Taxonomy Name | Military Ambulatory Procedure Visits Operational (Transportable) Clinic/Center
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 286500000X
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Taxonomy Name | Military Hospital
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 1710I1002X
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Taxonomy Name | Independent Duty Corpsman
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License Number |
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License Number State |
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