Provider Demographics
NPI:1174512453
Name:GOMEZ, DAVID BRENT (OD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:BRENT
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1623 ROBERT C. BYRD DR.
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801
Mailing Address - Country:US
Mailing Address - Phone:304-256-3937
Mailing Address - Fax:304-256-6574
Practice Address - Street 1:1623 ROBERT C. BYRD DR
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-8747
Practice Address - Country:US
Practice Address - Phone:304-256-3937
Practice Address - Fax:304-256-6574
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-19
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV926OD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0149804000Medicaid
WV0763312Medicare PIN
WVU49983Medicare UPIN
WV410032810Medicare PIN