Provider Demographics
NPI:1164591798
Name:GORDON, PHILLIP V (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:V
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 1:20 SEASHORE DR
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32561-2427
Mailing Address - Country:US
Mailing Address - Phone:434-996-4974
Mailing Address - Fax:
Practice Address - Street 1:5149 N 9TH AVE
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8756
Practice Address - Country:US
Practice Address - Phone:434-996-4974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101227934208000000X
LAMD.2017952080N0001X
FL1159522080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006714455Medicaid
LA1036340Medicaid
MS05921278Medicaid
VAH22277Medicare UPIN
VA006714455Medicaid
LA4N048Medicare PIN
MS05921278Medicaid