Provider Demographics
NPI:1053123166
Name:GOMEZ JACOME, ANDRES MAURICIO
Entity type:Individual
Prefix:
First Name:ANDRES
Middle Name:MAURICIO
Last Name:GOMEZ JACOME
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 1:800 N HOWARD AVE UNIT 352
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-1086
Mailing Address - Country:US
Mailing Address - Phone:321-890-9170
Mailing Address - Fax:
Practice Address - Street 1:800 N HOWARD AVE UNIT 352
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-1086
Practice Address - Country:US
Practice Address - Phone:321-890-9170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-24
Last Update Date:2025-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18-417246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant