Basic Information
Provider Information | |||||||||
NPI: | 1235321753 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GOMEZ | ||||||||
FirstName: | GILDA | ||||||||
MiddleName: | HAYDEE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1060 W 10TH ST | ||||||||
Address2: |   | ||||||||
City: | ROLLA | ||||||||
State: | MO | ||||||||
PostalCode: | 654012905 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5733649000 | ||||||||
FaxNumber: | 5734588445 | ||||||||
Practice Location | |||||||||
Address1: | 1060 W 10TH ST | ||||||||
Address2: |   | ||||||||
City: | ROLLA | ||||||||
State: | MO | ||||||||
PostalCode: | 65401 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5733649000 | ||||||||
FaxNumber: | 5734588445 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/17/2007 | ||||||||
LastUpdateDate: | 02/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/21/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | EMTL-2021-034 | GU | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RH0003X | 2009005169 | MO | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RX0202X | M7999 | TX | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | 207RH0003X | M-2296 | GU | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
No ID Information.