Provider Demographics
NPI:1386456465
Name:GOMEZ, GERARDO ANTONIO
Entity type:Individual
Prefix:
First Name:GERARDO
Middle Name:ANTONIO
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12360 83RD AVE APT 2A
Mailing Address - Street 2:
Mailing Address - City:KEW GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11415-3447
Mailing Address - Country:US
Mailing Address - Phone:917-648-9437
Mailing Address - Fax:
Practice Address - Street 1:12360 83RD AVE APT 2A
Practice Address - Street 2:
Practice Address - City:KEW GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11415-3447
Practice Address - Country:US
Practice Address - Phone:917-648-9437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-24
Last Update Date:2025-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033064225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist