Provider Demographics
NPI:1679783336
Name:GOMEZ HEREDIA, XIOMARA M
Entity type:Individual
Prefix:
First Name:XIOMARA
Middle Name:M
Last Name:GOMEZ HEREDIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 AVE PONCE DE LEON
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00907-4023
Mailing Address - Country:US
Mailing Address - Phone:787-960-6818
Mailing Address - Fax:787-725-4487
Practice Address - Street 1:1409 AVE PONCE DE LEON
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00907-4023
Practice Address - Country:US
Practice Address - Phone:787-960-6818
Practice Address - Fax:787-725-4487
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12088208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR12088OtherSTATE LICENCE