Basic Information
Provider Information | |||||||||
NPI: | 1609873504 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GOMEZ | ||||||||
FirstName: | JESUS | ||||||||
MiddleName: | ALBERTO | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SANCHEZ | ||||||||
OtherFirstName: | INES | ||||||||
OtherMiddleName: | JOAN | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 911230 | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 753911230 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9729978000 | ||||||||
FaxNumber: | 9722342987 | ||||||||
Practice Location | |||||||||
Address1: | 7848 GATEWAY BLVD E | ||||||||
Address2: |   | ||||||||
City: | EL PASO | ||||||||
State: | TX | ||||||||
PostalCode: | 799151815 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9155446750 | ||||||||
FaxNumber: | 9155991701 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/07/2005 | ||||||||
LastUpdateDate: | 03/08/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | H2409 | TX | N |   | Other Service Providers | Specialist |   | 207RX0202X | H2409 | WA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
ID | Type | State | Issuer | Description | 87629551 | 05 | NM |   | MEDICAID | 133951709 | 05 | TX |   | MEDICAID | 133951710 | 05 | TX |   | MEDICAID | 155014701 | 05 | TX |   | MEDICAID |