Provider Demographics
NPI:1023012523
Name:GORDON, STEPHEN M (DO)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:M
Last Name:GORDON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12330 METCALF AVE
Mailing Address - Street 2:STE. 420
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66213-1324
Mailing Address - Country:US
Mailing Address - Phone:913-323-9000
Mailing Address - Fax:913-323-9001
Practice Address - Street 1:12330 METCALF AVE
Practice Address - Street 2:STE. 420
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66213-1324
Practice Address - Country:US
Practice Address - Phone:913-323-9000
Practice Address - Fax:913-323-9001
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-13
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9794207V00000X
KS0519181207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO241356849Medicaid
MOC50876Medicare UPIN
KSG93000032Medicare PIN
KS100231380BMedicaid