Provider Demographics
NPI:1104833888
Name:GOMEZ, ANTONIO DIAZ (MD)
Entity type:Individual
Prefix:
First Name:ANTONIO
Middle Name:DIAZ
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3514 26TH ST
Mailing Address - Street 2:UNIT 2
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110-4414
Mailing Address - Country:US
Mailing Address - Phone:916-548-9991
Mailing Address - Fax:415-476-5712
Practice Address - Street 1:505 PARNASSUS AVE # M1094
Practice Address - Street 2:BOX 0111
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-2204
Practice Address - Country:US
Practice Address - Phone:415-476-5896
Practice Address - Fax:415-476-5712
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA86536207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A865360Medicaid
CA00A865360Medicare ID - Type Unspecified
I48916Medicare UPIN