Provider Demographics
NPI:1104671080
Name:GOMEZ, GUADALUPE GUILLEN (OD)
Entity type:Individual
Prefix:
First Name:GUADALUPE
Middle Name:GUILLEN
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:GUADALUPE
Other - Middle Name:
Other - Last Name:GOMEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:931 IDA BELLE ST
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:WA
Mailing Address - Zip Code:98944-9030
Mailing Address - Country:US
Mailing Address - Phone:509-643-6260
Mailing Address - Fax:
Practice Address - Street 1:2926 COVEY LN
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:WA
Practice Address - Zip Code:98944-8941
Practice Address - Country:US
Practice Address - Phone:509-836-2818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-23
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WA61566391152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program