Provider Demographics
NPI:1225221351
Name:ROBERT D GORDON MD PROFESSIONAL CORP
Entity Type:Organization
Organization Name:ROBERT D GORDON MD PROFESSIONAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-864-0404
Mailing Address - Street 1:PO BOX 74887
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44194-4887
Mailing Address - Country:US
Mailing Address - Phone:802-864-0404
Mailing Address - Fax:
Practice Address - Street 1:364 DORSET ST
Practice Address - Street 2:SUITE 204
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-6270
Practice Address - Country:US
Practice Address - Phone:802-864-0404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-22
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTVT9419Medicare PIN