Provider Demographics
NPI:1306092812
Name:KELLY A GOMEZ DPM PC
Entity type:Organization
Organization Name:KELLY A GOMEZ DPM PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:ALLAN
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:801-375-6677
Mailing Address - Street 1:777 N 500 W
Mailing Address - Street 2:SUITE 105
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-1541
Mailing Address - Country:US
Mailing Address - Phone:801-375-6677
Mailing Address - Fax:
Practice Address - Street 1:777 N 500 W
Practice Address - Street 2:SUITE 105
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-1541
Practice Address - Country:US
Practice Address - Phone:801-375-6677
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-15
Last Update Date:2009-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT367951261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT6210950001Medicare NSC
UT000064004Medicare PIN