Provider Demographics
NPI:1861524688
Name:GOMEZ, BETH S (PT)
Entity type:Individual
Prefix:
First Name:BETH
Middle Name:S
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8125
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92728-8125
Mailing Address - Country:US
Mailing Address - Phone:949-727-1858
Mailing Address - Fax:949-727-1868
Practice Address - Street 1:6865 ALTON PKWY
Practice Address - Street 2:SUITE 110
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3735
Practice Address - Country:US
Practice Address - Phone:949-727-1858
Practice Address - Fax:949-727-1868
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT26517204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT26517AMedicare ID - Type Unspecified