Provider Demographics
NPI:1073541819
Name:GORDON, MICHAEL LAWRENCE (DPM)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LAWRENCE
Last Name:GORDON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:17215 RED OAK DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77090-2697
Mailing Address - Country:US
Mailing Address - Phone:281-444-4114
Mailing Address - Fax:281-444-7789
Practice Address - Street 1:17215 RED OAK DR
Practice Address - Street 2:SUITE 102
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77090-2697
Practice Address - Country:US
Practice Address - Phone:281-444-4114
Practice Address - Fax:281-444-7789
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTX1487213E00000X
TX1487213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX480033891OtherRAILROAD MEDICARE
TX043773302Medicaid
TX4344700001OtherPALMETTO GBA
U79655Medicare UPIN
TX00285PMedicare ID - Type Unspecified