Basic Information
| Provider Information | |||||||||
| NPI: | 1518191493 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOMES | ||||||||
| FirstName: | OLUBUSOLA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9007 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229069007 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1221 LEE ST | ||||||||
| Address2: | 2ND FL | ||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229080001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349245219 | ||||||||
| FaxNumber: | 4349249720 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2009 | ||||||||
| LastUpdateDate: | 06/06/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 58764 | MN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RS0012X | 58764 | MN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RS0012X | 0101262025 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1518191493 | 05 | VA | MEDICAID |