Provider Demographics
NPI:1225016249
Name:GORDON, GEORGE RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:RICHARD
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 1:860 COPPER RD
Mailing Address - Street 2:COPPER MOUNTAIN CLINIC
Mailing Address - City:COPPER MOUNTAIN
Mailing Address - State:CO
Mailing Address - Zip Code:80443
Mailing Address - Country:US
Mailing Address - Phone:970-968-2330
Mailing Address - Fax:970-968-6681
Practice Address - Street 1:860 COPPER RD
Practice Address - Street 2:COPPER MOUNTAIN CLINIC
Practice Address - City:COPPER MOUNTAIN
Practice Address - State:CO
Practice Address - Zip Code:80443
Practice Address - Country:US
Practice Address - Phone:970-968-2330
Practice Address - Fax:970-968-6681
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN22608207P00000X
CO48127207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN080011997Medicaid
MND80148Medicare ID - Type Unspecified
MND80148Medicare UPIN