Provider Demographics
NPI:1699944512
Name:GOMEZ, JACOB JOHN (DME)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:JOHN
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:DME
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 PIONEER ST
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-3715
Mailing Address - Country:US
Mailing Address - Phone:562-665-8026
Mailing Address - Fax:714-446-9811
Practice Address - Street 1:1220 PIONEER ST
Practice Address - Street 2:UNIT B
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-3715
Practice Address - Country:US
Practice Address - Phone:562-665-8026
Practice Address - Fax:714-446-9811
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-25
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA9358262332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies