Provider Demographics
NPI:1033143466
Name:EKUBAN-GORDON, EDNA E (MD)
Entity Type:Individual
Prefix:
First Name:EDNA
Middle Name:E
Last Name:EKUBAN-GORDON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-1900
Mailing Address - Country:US
Mailing Address - Phone:276-666-7240
Mailing Address - Fax:
Practice Address - Street 1:320 HOSPITAL DR
Practice Address - Street 2:EMERGENCY DEPT.
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-1900
Practice Address - Country:US
Practice Address - Phone:276-666-7237
Practice Address - Fax:276-666-7600
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101221386207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005826900Medicaid
G97217Medicare UPIN
VA005826900Medicaid