Provider Demographics
NPI:1164427662
Name:HEALEY, GORDON BRUCE (MD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:BRUCE
Last Name:HEALEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3180 CENTRAL MALL DR
Mailing Address - Street 2:
Mailing Address - City:PORT ARTHUR
Mailing Address - State:TX
Mailing Address - Zip Code:77642-8039
Mailing Address - Country:US
Mailing Address - Phone:409-729-6231
Mailing Address - Fax:409-727-6537
Practice Address - Street 1:3180 CENTRAL MALL DR
Practice Address - Street 2:
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77642-8039
Practice Address - Country:US
Practice Address - Phone:409-729-6231
Practice Address - Fax:409-727-6537
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-20
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXE2602208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX115344702Medicaid
TX115344702Medicaid
TX87A307Medicare ID - Type Unspecified