Provider Demographics
NPI:1184656928
Name:GOMER, WILSON (MD)
Entity type:Individual
Prefix:
First Name:WILSON
Middle Name:
Last Name:GOMER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:WILSON
Other - Middle Name:
Other - Last Name:GOMER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1800 WESTERN AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92411-1352
Mailing Address - Country:US
Mailing Address - Phone:909-887-7427
Mailing Address - Fax:909-887-7430
Practice Address - Street 1:1800 N WESTERN AVE
Practice Address - Street 2:#103
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92411
Practice Address - Country:US
Practice Address - Phone:909-887-7427
Practice Address - Fax:909-887-7430
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA50690207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A506900Medicaid
F62407Medicare UPIN
CA00A506900Medicaid