Provider Demographics
NPI:1104051135
Name:GOMEZ, LEROY
Entity type:Individual
Prefix:
First Name:LEROY
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:513 E 9TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78572-4257
Mailing Address - Country:US
Mailing Address - Phone:956-424-1805
Mailing Address - Fax:956-424-1800
Practice Address - Street 1:513 E 9TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:MISSION
Practice Address - State:TX
Practice Address - Zip Code:78572-4257
Practice Address - Country:US
Practice Address - Phone:956-424-1805
Practice Address - Fax:956-424-1800
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-19
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1000046332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX6440770001Medicare NSC