Provider Demographics
NPI:1164614848
Name:KING, GORDON L (PT)
Entity Type:Individual
Prefix:MR
First Name:GORDON
Middle Name:L
Last Name:KING
Suffix:
Gender:M
Credentials:PT
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 378
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44871-0378
Mailing Address - Country:US
Mailing Address - Phone:419-609-1112
Mailing Address - Fax:419-609-1123
Practice Address - Street 1:6115 POWERS BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44129-5471
Practice Address - Country:US
Practice Address - Phone:440-888-7855
Practice Address - Fax:440-888-7862
Is Sole Proprietor?:No
Enumeration Date:2007-08-15
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT 003595225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2860720Medicaid
OH2860720Medicaid
OHH462631Medicare PIN
OHKI4219951Medicare PIN