Provider Demographics
NPI:1366431835
Name:GOMEZ, ENEIDA (MD)
Entity type:Individual
Prefix:
First Name:ENEIDA
Middle Name:
Last Name: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:PO BOX 3123
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32085-3123
Mailing Address - Country:US
Mailing Address - Phone:904-824-4990
Mailing Address - Fax:
Practice Address - Street 1:1750 TREE BLVD
Practice Address - Street 2:STE 5
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-5715
Practice Address - Country:US
Practice Address - Phone:904-342-0672
Practice Address - Fax:904-342-0673
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-18
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME834442084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL262635701Medicaid
FL04342OtherBCBS
FL262635700Medicaid
FLP00661782OtherRR MEDICARE
FL04342OtherBCBS
FLG79184Medicare UPIN
FL262635700Medicaid