Basic Information
| Provider Information | |||||||||
| NPI: | 1548617590 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOMEZ | ||||||||
| FirstName: | JAVIER | ||||||||
| MiddleName: | OMAR | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GOMEZ-NOLASCO | ||||||||
| OtherFirstName: | JAVIER | ||||||||
| OtherMiddleName: | OMAR | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | D.O | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3 UNIVERSITY PLZ STE 205 | ||||||||
| Address2: | |||||||||
| City: | HACKENSACK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076016208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2018333000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3196 KENNEDY BLVD STE 2 | ||||||||
| Address2: | |||||||||
| City: | UNION CITY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070872468 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2017959080 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2016 | ||||||||
| LastUpdateDate: | 08/23/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 25MB11152100 | NJ | Y | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.