Provider Demographics
NPI:1174511257
Name:PRINGLE, GORDON A (DDS PHD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:A
Last Name:PRINGLE
Suffix:
Gender:M
Credentials:DDS PHD
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 827783
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-7783
Mailing Address - Country:US
Mailing Address - Phone:215-707-2930
Mailing Address - Fax:
Practice Address - Street 1:3401 N BROAD ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5103
Practice Address - Country:US
Practice Address - Phone:215-707-4353
Practice Address - Fax:215-707-2053
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS030417L207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1010266950001Medicaid
007442FZUMedicare ID - Type Unspecified
PA1010266950001Medicaid