Provider Demographics
NPI:1053392472
Name:GOMEZ, TESSA (MD)
Entity type:Individual
Prefix:
First Name:TESSA
Middle Name:
Last Name:GOMEZ
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:PO BOX 95000-2433
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19195-2433
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10 UNION SQ E
Practice Address - Street 2:SUITE 3F
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-3314
Practice Address - Country:US
Practice Address - Phone:212-844-5716
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-11
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY209828207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01813996Medicaid
NY33N581Medicare ID - Type Unspecified
NY01813996Medicaid