Provider Demographics
NPI:1225021546
Name:GORDON, ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
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 1:826 WASHINGTON RD
Mailing Address - Street 2:SUITE 209
Mailing Address - City:WESTMINSTER
Mailing Address - State:MD
Mailing Address - Zip Code:21157-5750
Mailing Address - Country:US
Mailing Address - Phone:410-840-8203
Mailing Address - Fax:410-751-2816
Practice Address - Street 1:826 WASHINGTON RD
Practice Address - Street 2:SUITE 209
Practice Address - City:WESTMINSTER
Practice Address - State:MD
Practice Address - Zip Code:21157-5750
Practice Address - Country:US
Practice Address - Phone:410-840-8203
Practice Address - Fax:410-751-2816
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD20554174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD309904100Medicaid
MDE13517Medicare UPIN
MD309904100Medicaid