Provider Demographics
NPI:1851045447
Name:GOMEZ-MEDINA, MARIA DE JESUS (LICAC, MSOM)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:DE JESUS
Last Name:GOMEZ-MEDINA
Suffix:
Gender:F
Credentials:LICAC, MSOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 MERRY TRL
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-1329
Mailing Address - Country:US
Mailing Address - Phone:210-663-4643
Mailing Address - Fax:
Practice Address - Street 1:103 N PARK BLVD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78204-2430
Practice Address - Country:US
Practice Address - Phone:210-874-6617
Practice Address - Fax:210-783-9320
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-11
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAC02042171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist