Basic Information
| Provider Information | |||||||||
| NPI: | 1366911471 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOMEZ VIZCARRA | ||||||||
| FirstName: | JORGE | ||||||||
| MiddleName: | MANUEL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1214 MARINER BLVD | ||||||||
| Address2: | |||||||||
| City: | SPRING HILL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346095657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522775305 | ||||||||
| FaxNumber: | 3526160906 | ||||||||
| Practice Location | |||||||||
| Address1: | 14900 W DIXIE HWY | ||||||||
| Address2: | |||||||||
| City: | NORTH MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331811018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3059950539 | ||||||||
| FaxNumber: | 3059950538 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2018 | ||||||||
| LastUpdateDate: | 03/24/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 21111 | PR | N | Allopathic & Osteopathic Physicians | General Practice | 208D00000X | ACN1356 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 111375300 | 05 | FL | MEDICAID |