Provider Demographics
NPI:1003952573
Name:GORDON, WAYNE (DC)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:
Last Name:GORDON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 PONTE VEDRA PARK DR
Mailing Address - Street 2:SUITE 800
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-6613
Mailing Address - Country:US
Mailing Address - Phone:904-418-3937
Mailing Address - Fax:
Practice Address - Street 1:228 PONTE VEDRA PARK DR
Practice Address - Street 2:SUITE 800
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-6613
Practice Address - Country:US
Practice Address - Phone:904-418-3937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR008143111N00000X, 111NR0400X
FLCH9576111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCJVGMedicare PIN
GAV11698Medicare UPIN