Provider Demographics
NPI:1124010640
Name:GORDON, GARY G (DO)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:G
Last Name:GORDON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 12TH ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-4158
Mailing Address - Country:US
Mailing Address - Phone:601-703-9265
Mailing Address - Fax:601-703-9936
Practice Address - Street 1:1800 12TH ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-4158
Practice Address - Country:US
Practice Address - Phone:601-703-9265
Practice Address - Fax:601-703-9401
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS07448207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04458061Medicaid
AL73003105OtherBLUE CROSS OF AL
AL000039981OtherMEDICAID OF AL
MS0130017OtherUNITED HEALTH CARE
080030813OtherRAILROAD MEDICARE
MS04458061Medicaid
AL73003105OtherBLUE CROSS OF AL