Provider Demographics
NPI:1538898929
Name:GOMEZ, GABRIELLE
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2657 120TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-8692
Mailing Address - Country:US
Mailing Address - Phone:616-395-0606
Mailing Address - Fax:
Practice Address - Street 1:2657 120TH AVE
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-8692
Practice Address - Country:US
Practice Address - Phone:616-395-0606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-09
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901005621152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist