Basic Information
| Provider Information | |||||||||
| NPI: | 1215030630 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOMEZ LOPEZ | ||||||||
| FirstName: | WANDA | ||||||||
| MiddleName: | Y | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GOMEZ LOPEZ | ||||||||
| OtherFirstName: | WANDA | ||||||||
| OtherMiddleName: | Y | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 121 S ORANGE AVE STE 940 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328013234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076589687 | ||||||||
| FaxNumber: | 4072864515 | ||||||||
| Practice Location | |||||||||
| Address1: | 910 W VINE ST | ||||||||
| Address2: | |||||||||
| City: | KISSIMMEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347414165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4075179582 | ||||||||
| FaxNumber: | 4079786644 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2006 | ||||||||
| LastUpdateDate: | 04/06/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | ACN1011 | FL | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | FG6400066 | 01 | FL | DEA CERTIFICATE | OTHER |