Basic Information
| Provider Information | |||||||||
| NPI: | 1477974608 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RICHARD GOMEZ MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3706 | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834033706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085252090 | ||||||||
| FaxNumber: | 2085238978 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 BUFFALO WAY | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 830022530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077338677 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2013 | ||||||||
| LastUpdateDate: | 12/13/2013 | ||||||||
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| AuthorizedOfficialLastName: | GOMEZ | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4806857965 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 9341A | WY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.