Provider Demographics
NPI:1730221250
Name:GOMM, GERALD EDWARD (DC)
Entity type:Individual
Prefix:MR
First Name:GERALD
Middle Name:EDWARD
Last Name:GOMM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 PLANK ROAD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:KAUKAUNA
Mailing Address - State:WI
Mailing Address - Zip Code:54130-1602
Mailing Address - Country:US
Mailing Address - Phone:920-766-7118
Mailing Address - Fax:
Practice Address - Street 1:111 PLANK ROAD
Practice Address - Street 2:SUITE 130
Practice Address - City:KAUKAUNA
Practice Address - State:WI
Practice Address - Zip Code:54130-1602
Practice Address - Country:US
Practice Address - Phone:920-766-7118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI350012111N00000X
WI3500-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
U86526Medicare UPIN