Provider Demographics
NPI:1003868878
Name:GORDON, RICHARD STEVEN (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:STEVEN
Last Name:GORDON
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 1:10957 NORTHGREEN DR
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33449-8054
Mailing Address - Country:US
Mailing Address - Phone:561-642-4878
Mailing Address - Fax:
Practice Address - Street 1:10957 NORTHGREEN DR
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33449-8054
Practice Address - Country:US
Practice Address - Phone:561-642-4878
Practice Address - Fax:561-642-4878
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL969102085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0752592Medicaid
127593300OtherUS DEPARTMENT OF LABOR
OH341212779007OtherMEDICAL MUTUAL
300016814OtherRAILROAD MEDICARE
OH341212779020OtherMEDICAL MUTUAL OF OH
OH000000026343OtherANTHEM
OH027978400OtherFED BLK LNG
OH341212779007OtherMEDICAL MUTUAL
OH0752592Medicaid
OH027978400OtherFED BLK LNG