Provider Demographics
NPI:1669776373
Name:GOMES, SHANDA MARIEL (MD)
Entity type:Individual
Prefix:
First Name:SHANDA
Middle Name:MARIEL
Last Name:GOMES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1058 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80206-3524
Mailing Address - Country:US
Mailing Address - Phone:303-333-4069
Mailing Address - Fax:
Practice Address - Street 1:555 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:ESTES PARK
Practice Address - State:CO
Practice Address - Zip Code:80517-6312
Practice Address - Country:US
Practice Address - Phone:303-333-4069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-10
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA115657207P00000X
CO0052647207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine