Provider Demographics
NPI:1356489132
Name:GOMES, MARCELLO P (MD)
Entity type:Individual
Prefix:DR
First Name:MARCELLO
Middle Name:P
Last Name:GOMES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MARCELLO
Other - Middle Name:P
Other - Last Name:VILLA-FORTE GOMES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:6000 W CREEK RD
Mailing Address - Street 2:SUITE 10
Mailing Address - City:INDEPENDENCE
Mailing Address - State:OH
Mailing Address - Zip Code:44131-2139
Mailing Address - Country:US
Mailing Address - Phone:800-223-2273
Mailing Address - Fax:
Practice Address - Street 1:9500 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44195-0001
Practice Address - Country:US
Practice Address - Phone:800-223-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35075247G207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2771791Medicaid
OH2771791Medicaid