Basic Information
Provider Information | |||||||||
NPI: | 1851968697 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GOMEZ | ||||||||
FirstName: | JAIME | ||||||||
MiddleName: | N/A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 24301 SOUTHLAND DR STE 300 | ||||||||
Address2: |   | ||||||||
City: | HAYWARD | ||||||||
State: | CA | ||||||||
PostalCode: | 945451546 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 24301 SOUTHLAND DR | ||||||||
Address2: |   | ||||||||
City: | HAYWARD | ||||||||
State: | CA | ||||||||
PostalCode: | 945451542 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5108815921 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/09/2021 | ||||||||
LastUpdateDate: | 06/07/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/30/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   | CA | Y |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   |
ID Information
ID | Type | State | Issuer | Description | $$$$$$$$$ | 05 | CA |   | MEDICAID |