Provider Demographics
NPI:1164535142
Name:GORDON, CHARLES R (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:R
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 6605
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75711-6605
Mailing Address - Country:US
Mailing Address - Phone:903-592-6000
Mailing Address - Fax:903-595-1592
Practice Address - Street 1:2737 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-5413
Practice Address - Country:US
Practice Address - Phone:903-592-6000
Practice Address - Fax:903-592-3224
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH5238207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX132287707Medicaid
8K6190OtherBLUE CROSS BLUE SHIELD
TX8B2239Medicare PIN
8K6190OtherBLUE CROSS BLUE SHIELD