Provider Demographics
NPI:1164745824
Name:GORDON, SCOTT WILLIAM (DPM)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:WILLIAM
Last Name:GORDON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 WATSON ST STE 300
Mailing Address - Street 2:
Mailing Address - City:PRATT
Mailing Address - State:KS
Mailing Address - Zip Code:67124-3092
Mailing Address - Country:US
Mailing Address - Phone:620-672-1002
Mailing Address - Fax:620-450-1741
Practice Address - Street 1:203 WATSON ST STE 300
Practice Address - Street 2:
Practice Address - City:PRATT
Practice Address - State:KS
Practice Address - Zip Code:67124-3092
Practice Address - Country:US
Practice Address - Phone:620-672-1002
Practice Address - Fax:620-450-1741
Is Sole Proprietor?:No
Enumeration Date:2010-03-10
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM345213ES0103X
AZ0738213ES0103X
KS1200396213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery