Provider Demographics
NPI:1225078215
Name:GORDON, JOEL P (MD)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:P
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 1:424 S COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:ATLANTIS
Mailing Address - State:FL
Mailing Address - Zip Code:33462-1204
Mailing Address - Country:US
Mailing Address - Phone:561-572-8183
Mailing Address - Fax:561-370-6098
Practice Address - Street 1:424 S COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:ATLANTIS
Practice Address - State:FL
Practice Address - Zip Code:33462-1204
Practice Address - Country:US
Practice Address - Phone:561-572-8183
Practice Address - Fax:561-370-6098
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME19252207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D55780Medicare UPIN
FL50668Medicare ID - Type Unspecified