Provider Demographics
NPI:1083885891
Name:GORDLEY PLASTIC SURGERY PA
Entity Type:Organization
Organization Name:GORDLEY PLASTIC SURGERY PA
Other - Org Name:KYLE P GORDLEY MD
Other - Org Type:Other Name
Authorized Official - Title/Position:M.D./OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:GORDLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:832-813-5839
Mailing Address - Street 1:129 VISION PARK BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:SHENANDOAH
Mailing Address - State:TX
Mailing Address - Zip Code:77384-3024
Mailing Address - Country:US
Mailing Address - Phone:832-813-5839
Mailing Address - Fax:832-813-8512
Practice Address - Street 1:129 VISION PARK BLVD STE 210
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:TX
Practice Address - Zip Code:77384-3024
Practice Address - Country:US
Practice Address - Phone:832-813-5839
Practice Address - Fax:832-813-8512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-19
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM72222086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDP0233OtherRR MC PIN
TX336661901Medicaid
TXDP0233OtherRR MC PIN