Provider Demographics
NPI:1043703705
Name:GORDNIER, THERESIA
Entity Type:Individual
Prefix:
First Name:THERESIA
Middle Name:
Last Name:GORDNIER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45324-2640
Mailing Address - Country:US
Mailing Address - Phone:937-245-7200
Mailing Address - Fax:
Practice Address - Street 1:725 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45324-2640
Practice Address - Country:US
Practice Address - Phone:937-245-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-07
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01085834A207Q00000X
KS94-09567207Q00000X
OH35.145760207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300050316Medicaid
OH0495495Medicaid