Provider Demographics
NPI:1073748281
Name:GORDON, JENNIFER ROSE (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:ROSE
Last Name:GORDON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5301 DAVIS LN STE 100
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78749-4061
Mailing Address - Country:US
Mailing Address - Phone:512-615-2730
Mailing Address - Fax:512-666-3764
Practice Address - Street 1:5301 DAVIS LN STE 100
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78749-4061
Practice Address - Country:US
Practice Address - Phone:512-615-2730
Practice Address - Fax:512-566-3612
Is Sole Proprietor?:No
Enumeration Date:2009-05-18
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP5367207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8EK794OtherBCBS PROVIDER RECORD ID
TX8EK794OtherBCBS PROVIDER RECORD ID