Provider Demographics
NPI:1306204813
Name:GOMEZ, JULIE BRODERICK
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:BRODERICK
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 635283
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5283
Mailing Address - Country:US
Mailing Address - Phone:589-344-5555
Mailing Address - Fax:
Practice Address - Street 1:334 THOMAS MORE PKWY
Practice Address - Street 2:
Practice Address - City:CRESTVIEW HILLS
Practice Address - State:KY
Practice Address - Zip Code:41017-3464
Practice Address - Country:US
Practice Address - Phone:859-578-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-29
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY53821208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics