Provider Demographics
NPI:1043432008
Name:WAYNE H. GORDON, MD
Entity Type:Organization
Organization Name:WAYNE H. GORDON, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EDI COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MAUREEN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:CRAVEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-295-4208
Mailing Address - Street 1:14607 SAN PEDRO AVE STE 220
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-4356
Mailing Address - Country:US
Mailing Address - Phone:281-295-4208
Mailing Address - Fax:281-295-4065
Practice Address - Street 1:14607 SAN PEDRO AVE STE 220
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-4356
Practice Address - Country:US
Practice Address - Phone:281-295-4208
Practice Address - Fax:281-295-4065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0017BRMedicare PIN