Provider Demographics
NPI:1215043013
Name:GORDON, PAUL H (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:H
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 1:621 S ILLINOIS AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MASON CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50401-5489
Mailing Address - Country:US
Mailing Address - Phone:641-494-3041
Mailing Address - Fax:641-494-3059
Practice Address - Street 1:1010 4TH ST SW
Practice Address - Street 2:
Practice Address - City:MASON CITY
Practice Address - State:IA
Practice Address - Zip Code:50401-2857
Practice Address - Country:US
Practice Address - Phone:641-422-6020
Practice Address - Fax:641-422-7803
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA20471207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0150425Medicaid
IA12236OtherWELLMARK
IA48803Medicare ID - Type Unspecified
IA12236OtherWELLMARK