MEDICARE: DEMARIS GOMEZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	1704349	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	174400000X	OTHER	NY	SERVICE PROVIDER

General Provider Information

NPI Number	:	1053674572
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEMARIS GOMEZ

Provider Business Mailing Address
First Line	:	369 E 148TH ST
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10455-4041
Country	:	US
Telephone Number	:	718-769-2698
Fax Number	:

Provider Business Practice Location Address
First Line	:	369 E 148TH ST
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10455-4041
Country	:	US
Telephone Number	:	718-769-2698
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/19/2012
Last Update Date	:	06/19/2012

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Directions to “ DEMARIS GOMEZ ” Practice Location

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