Provider Demographics
NPI:1154310761
Name:PAGE, GORDON A JR (MD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:A
Last Name:PAGE
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2177
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:FL
Mailing Address - Zip Code:34265-2177
Mailing Address - Country:US
Mailing Address - Phone:863-494-3535
Mailing Address - Fax:836-491-4328
Practice Address - Street 1:888 N ROBERT AVE
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:FL
Practice Address - Zip Code:34266-9580
Practice Address - Country:US
Practice Address - Phone:863-494-8401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIGP041179207Q00000X
FLME97222207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1729834Medicaid
FL2771641 00Medicaid
MIA77712Medicare UPIN
FL2771641 00Medicaid
MI1729834Medicaid