Provider Demographics
NPI:1962981282
Name:GOMEZ, ROBERT ANTONIO
Entity type:Individual
Prefix:
First Name:ROBERT
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:PO BOX 28374
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92809-0145
Mailing Address - Country:US
Mailing Address - Phone:714-616-0639
Mailing Address - Fax:
Practice Address - Street 1:1400 EMELINE AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-1976
Practice Address - Country:US
Practice Address - Phone:714-616-0639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-08
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251K00000X, 261QP0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
No251K00000XAgenciesPublic Health or Welfare