Basic Information
| Provider Information | |||||||||
| NPI: | 1588927602 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOMEZ | ||||||||
| FirstName: | WYLIE | ||||||||
| MiddleName: | ELAURIA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 245 N 15TH ST | ||||||||
| Address2: | MAIL STOP 427 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191021101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157627916 | ||||||||
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| Practice Location | |||||||||
| Address1: | 245 N 15TH ST | ||||||||
| Address2: | MAIL STOP 427 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191021101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157627916 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2012 | ||||||||
| LastUpdateDate: | 02/05/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MT202797 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 2085R0204X | 54626 | AZ | Y | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
No ID Information.