Provider Demographics
NPI:1538350848
Name:GOMEZ-MEDINA, OMAR (MD)
Entity type:Individual
Prefix:DR
First Name:OMAR
Middle Name:
Last Name:GOMEZ-MEDINA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:658 CALLE MIRAMAR
Mailing Address - Street 2:APT 1201
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00907-3450
Mailing Address - Country:US
Mailing Address - Phone:787-640-5362
Mailing Address - Fax:
Practice Address - Street 1:ID14 CALLE ALMACIGO
Practice Address - Street 2:EXT. ROYAL PALM
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00956-3104
Practice Address - Country:US
Practice Address - Phone:787-288-0808
Practice Address - Fax:787-288-0888
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-05
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR17595208100000X, 2081N0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081N0008XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationNeuromuscular Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRCM165AMedicare PIN