Provider Demographics
NPI:1316571912
Name:DE PENA GOMEZ, CHARITIN (MD)
Entity type:Individual
Prefix:DR
First Name:CHARITIN
Middle Name:
Last Name:DE PENA GOMEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 ASHWOOD PKWY APT 1240
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30338-7514
Mailing Address - Country:US
Mailing Address - Phone:787-525-8376
Mailing Address - Fax:
Practice Address - Street 1:601 PROFESSIONAL DR OFC 220A
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-7698
Practice Address - Country:US
Practice Address - Phone:770-709-6922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-24
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR21702208D00000X
GA100027207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice