Provider Demographics
NPI:1144213414
Name:GORDON, KARYN BAYYINAH (MD)
Entity Type:Individual
Prefix:
First Name:KARYN
Middle Name:BAYYINAH
Last Name:GORDON
Suffix:
Gender:F
Credentials:MD
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 344
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27102-0344
Mailing Address - Country:US
Mailing Address - Phone:336-716-2255
Mailing Address - Fax:336-725-2173
Practice Address - Street 1:2295 E 14TH ST
Practice Address - Street 2:STE 100
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27105-6804
Practice Address - Country:US
Practice Address - Phone:336-716-2255
Practice Address - Fax:336-725-2173
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC98-00875208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7910406Medicaid
NC2257310CMedicare PIN