Provider Demographics
NPI:1093888232
Name:GORDON, BRYAN (DC)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:GORDON
Suffix:
Gender:M
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:PO BOX 95928
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-0928
Mailing Address - Country:US
Mailing Address - Phone:801-562-1531
Mailing Address - Fax:801-562-1534
Practice Address - Street 1:2618 W 7800 S
Practice Address - Street 2:SUITE #200
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-4208
Practice Address - Country:US
Practice Address - Phone:801-562-1531
Practice Address - Fax:801-562-1534
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2774306-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT27743061202001OtherREGENCE BLUE CROSS NUMBER
UTU82167Medicare UPIN
UT000012358Medicare ID - Type Unspecified