Provider Demographics
NPI:1144397217
Name:GORDON, DOUGLAS M (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:M
Last Name:GORDON
Suffix:
Gender:M
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 2400
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32902-2400
Mailing Address - Country:US
Mailing Address - Phone:866-744-1461
Mailing Address - Fax:770-621-3181
Practice Address - Street 1:701 W COCOA BEACH CSWY
Practice Address - Street 2:
Practice Address - City:COCOA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32931-3585
Practice Address - Country:US
Practice Address - Phone:321-799-7111
Practice Address - Fax:770-621-3181
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME641942085B0100X, 2085N0904X, 2085P0229X, 2085R0202X, 2085R0204X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL23388OtherBCBS
300048844OtherMEDICARE RR
FL23388ZOtherMEDICARE PTAN
FL377261600Medicaid
F25642Medicare UPIN