Provider Demographics
NPI:1164656831
Name:GORDON, LEA LYNNE (MD)
Entity Type:Individual
Prefix:DR
First Name:LEA
Middle Name:LYNNE
Last Name:GORDON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 S 10TH ST
Mailing Address - Street 2:285K
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5244
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:132 S 10TH ST
Practice Address - Street 2:285K
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5244
Practice Address - Country:US
Practice Address - Phone:215-503-5642
Practice Address - Fax:215-503-4817
Is Sole Proprietor?:No
Enumeration Date:2009-05-11
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC156859390200000X
PAMD451503207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program