Provider Demographics
NPI:1588927602
Name:GOMEZ, WYLIE ELAURIA (MD)
Entity type:Individual
Prefix:
First Name:WYLIE
Middle Name:ELAURIA
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 N 15TH ST
Mailing Address - Street 2:MAIL STOP 427
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-1101
Mailing Address - Country:US
Mailing Address - Phone:215-762-7916
Mailing Address - Fax:
Practice Address - Street 1:245 N 15TH ST
Practice Address - Street 2:MAIL STOP 427
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-1101
Practice Address - Country:US
Practice Address - Phone:215-762-7916
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-22
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT202797207R00000X
AZ546262085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine