Provider Demographics
NPI:1104818129
Name:GOMEZ, JOSE R (MD)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:R
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:550 MOUNT PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07104-1530
Mailing Address - Country:US
Mailing Address - Phone:973-482-4697
Mailing Address - Fax:973-482-0893
Practice Address - Street 1:550 MOUNT PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07104-1530
Practice Address - Country:US
Practice Address - Phone:973-482-4697
Practice Address - Fax:973-482-0893
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJMA029163207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJG0452413Medicare ID - Type Unspecified
C55324Medicare UPIN