Provider Demographics
NPI:1225065774
Name:GORDON, GARY (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:GORDON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 LANCASTER AVENUE
Mailing Address - Street 2:SUITE 137
Mailing Address - City:WYNNEWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19096
Mailing Address - Country:US
Mailing Address - Phone:610-896-8400
Mailing Address - Fax:610-896-9652
Practice Address - Street 1:100 E LANCASTER AVE
Practice Address - Street 2:SUITE 137 LANKENAU MEDICAL BLDG.
Practice Address - City:WYNNEWOOD
Practice Address - State:PA
Practice Address - Zip Code:19096-3450
Practice Address - Country:US
Practice Address - Phone:610-896-8400
Practice Address - Fax:610-896-9652
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD017706E207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA11966Medicaid
PA11966Medicaid
PA027727Medicare ID - Type Unspecified