MEDICARE: JOSE R GOMEZ MD

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	207R00000X	Internal Medicine Physician	MA029163	NJ

General Provider Information

NPI Number	:	1104818129
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSE R GOMEZ MD

Provider Business Mailing Address
First Line	:	550 MOUNT PROSPECT AVE
Second Line	:
City	:	NEWARK
State	:	NJ
Zip	:	07104-1530
Country	:	US
Telephone Number	:	973-482-4697
Fax Number	:	973-482-0893

Provider Business Practice Location Address
First Line	:	550 MOUNT PROSPECT AVE
Second Line	:
City	:	NEWARK
State	:	NJ
Zip	:	07104-1530
Country	:	US
Telephone Number	:	973-482-4697
Fax Number	:	973-482-0893

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

Provider Enumeration Date	:	08/16/2005
Last Update Date	:	07/08/2007

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