Provider Demographics
NPI:1023002300
Name:GORDON CLINIC-ANTONIO GORDON MD PA
Entity Type:Organization
Organization Name:GORDON CLINIC-ANTONIO GORDON MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:M
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:305-556-6459
Mailing Address - Street 1:344 W 65TH ST
Mailing Address - Street 2:SUITE 201-204
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-6719
Mailing Address - Country:US
Mailing Address - Phone:305-556-6459
Mailing Address - Fax:305-556-9623
Practice Address - Street 1:344 W 65TH ST
Practice Address - Street 2:SUITE 201-204
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-6719
Practice Address - Country:US
Practice Address - Phone:305-556-6459
Practice Address - Fax:305-556-9623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-01
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL133N00000X, 207RC0000X
FL0028982207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL036786900Medicaid
FL79262OtherBLUE CROSS BLUE SHIELD
FL036786900Medicaid
FL79262Medicare ID - Type UnspecifiedMEDICARE