Basic Information
| Provider Information | |||||||||
| NPI: | 1700308913 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SANCHEZ GOMEZ | ||||||||
| FirstName: | JOSE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 78866 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532788866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7796967150 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1700 HENRY LUCKOW LN | ||||||||
| Address2: | |||||||||
| City: | BELVIDERE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610081702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7796968650 | ||||||||
| FaxNumber: | 8155444691 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2017 | ||||||||
| LastUpdateDate: | 02/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 125-070965 | IL | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 036-153617 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.