Provider Demographics
NPI:1689677262
Name:DIEGUEZ GOMEZ, GERARDO J (MD)
Entity type:Individual
Prefix:
First Name:GERARDO
Middle Name:J
Last Name:DIEGUEZ GOMEZ
Suffix:
Gender:M
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 2699
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32513-2699
Mailing Address - Country:US
Mailing Address - Phone:850-475-4500
Mailing Address - Fax:850-650-2787
Practice Address - Street 1:36500 EMERALD COAST PKWY
Practice Address - Street 2:
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-4713
Practice Address - Country:US
Practice Address - Phone:850-837-0032
Practice Address - Fax:850-650-2787
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME89001207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL269830700Medicaid
FL269830700Medicaid
FL269830700Medicaid