Provider Demographics
NPI:1316940612
Name:GOMEZ-JORGE, JACKELINE T (MD)
Entity type:Individual
Prefix:DR
First Name:JACKELINE
Middle Name:T
Last Name:GOMEZ-JORGE
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 1:401 MIRACLE MILE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134
Mailing Address - Country:US
Mailing Address - Phone:888-211-9355
Mailing Address - Fax:
Practice Address - Street 1:401 MIRACLE MILE
Practice Address - Street 2:SUITE 103
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134
Practice Address - Country:US
Practice Address - Phone:888-211-9355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME-667522085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL35884OtherBLUE SHIELD
FL179079OtherJACKSON MEMORIAL
FL2594153-00Medicaid
FL272922OtherAVMED
FL5020703OtherAETNA
FL6643476OtherCIGNA
FL48767OtherNEIGHBORHOOD HEALTH PLAN
FL48767OtherNEIGHBORHOOD HEALTH PLAN
FL35884OtherBLUE SHIELD