Provider Demographics
NPI:1053324988
Name:GORDON, TIMOTHY EUGENE (OD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:EUGENE
Last Name:GORDON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22683
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87502-2683
Mailing Address - Country:US
Mailing Address - Phone:575-639-4767
Mailing Address - Fax:505-424-1384
Practice Address - Street 1:5701 HERRERA DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-2677
Practice Address - Country:US
Practice Address - Phone:505-424-9139
Practice Address - Fax:505-424-1384
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2274152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000P4328Medicaid
NMT74972Medicare UPIN