Provider Demographics
NPI:1194748079
Name:GOMEZ, ORLANDO (DO)
Entity type:Individual
Prefix:
First Name:ORLANDO
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49-4 REVERE RD
Mailing Address - Street 2:
Mailing Address - City:DREXEL HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19026-5331
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:49-4 REVERE RD
Practice Address - Street 2:
Practice Address - City:DREXEL HILL
Practice Address - State:PA
Practice Address - Zip Code:19026-5331
Practice Address - Country:US
Practice Address - Phone:215-620-6487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS013116207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1688546OtherB SHIELD BLUE CHOICE
088455R81OtherMEDICARE ID - TYPE UNSPECIFIED
PA14990OtherELDER HEALTH
7218638OtherAETNA
PA4670180001Medicaid
PA2361142OtherIBC
2361142000OtherKEYSTONE
7218638OtherAETNA