Provider Demographics
NPI:1063504041
Name:GORDON, LISA JANE (DC)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:JANE
Last Name:GORDON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5053 DURHAM RD W
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-1449
Mailing Address - Country:US
Mailing Address - Phone:410-733-5231
Mailing Address - Fax:
Practice Address - Street 1:5053 DURHAM RD W
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-1449
Practice Address - Country:US
Practice Address - Phone:410-733-5231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01372111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD918L374EMedicare PIN