Provider Demographics
NPI:1548845282
Name:GOMEZ, CAMILO
Entity type:Individual
Prefix:
First Name:CAMILO
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10201 HAMMOCKS BLVD STE 122
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33196-3783
Mailing Address - Country:US
Mailing Address - Phone:786-701-8702
Mailing Address - Fax:
Practice Address - Street 1:10201 HAMMOCKS BLVD STE 122
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33196-3783
Practice Address - Country:US
Practice Address - Phone:786-701-8702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-15
Last Update Date:2025-01-02
Deactivation Date:2024-01-12
Deactivation Code:
Reactivation Date:2024-03-11
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11030249363LP0808X, 207R00000X
FL11030249363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine