Provider Demographics
NPI:1144217480
Name:GORDON, JEREMY MICHAEL (DC)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:MICHAEL
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 1:905 N STONE ST
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-2521
Mailing Address - Country:US
Mailing Address - Phone:386-734-9995
Mailing Address - Fax:386-734-9949
Practice Address - Street 1:905 N STONE ST
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-2521
Practice Address - Country:US
Practice Address - Phone:386-734-9995
Practice Address - Fax:386-734-9949
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH7770111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL381193000Medicaid
FL55875Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
FL381193000Medicaid