Provider Demographics
NPI:1043301096
Name:GORDON, TODD RUSSELL (MD)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:RUSSELL
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 1:123 PINE ST
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59601-6360
Mailing Address - Country:US
Mailing Address - Phone:406-457-0091
Mailing Address - Fax:
Practice Address - Street 1:1892 WILLIAMS ST
Practice Address - Street 2:VA MEDICAL CENTER
Practice Address - City:FORT HARRISON
Practice Address - State:MT
Practice Address - Zip Code:59636
Practice Address - Country:US
Practice Address - Phone:406-447-7476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD 21158207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine