Basic Information
| Provider Information | |||||||||
| NPI: | 1790197721 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOMEZ | ||||||||
| FirstName: | MIGUEL | ||||||||
| MiddleName: | CUAUHTEMOC | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 160 | ||||||||
| Address2: | |||||||||
| City: | SHIPROCK | ||||||||
| State: | NM | ||||||||
| PostalCode: | 874200160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053686001 | ||||||||
| FaxNumber: | 5053687011 | ||||||||
| Practice Location | |||||||||
| Address1: | 5608 ZUNI RD SE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871082926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052622481 | ||||||||
| FaxNumber: | 5052657045 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2014 | ||||||||
| LastUpdateDate: | 09/06/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A143066 | CA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD2019-0802 | NM | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.