Basic Information
| Provider Information | |||||||||
| NPI: | 1205943206 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOMEZ | ||||||||
| FirstName: | LIZETTE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 87 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782910087 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103589172 | ||||||||
| FaxNumber: | 2103589183 | ||||||||
| Practice Location | |||||||||
| Address1: | 903 W MARTIN ST | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782070903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103585437 | ||||||||
| FaxNumber: | 2103585890 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2006 | ||||||||
| LastUpdateDate: | 08/11/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | J4158 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 125070608 | 05 | TX | MEDICAID | 125070609 | 01 | TX | CSHCN | OTHER |