Provider Demographics
NPI:1235121955
Name:GORDON, RICHARD SHAWN (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:SHAWN
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 1:1258 W BAY DR STE D
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33770-2277
Mailing Address - Country:US
Mailing Address - Phone:727-586-3751
Mailing Address - Fax:727-587-9340
Practice Address - Street 1:1258 W BAY DR STE D
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33770-2277
Practice Address - Country:US
Practice Address - Phone:727-586-3751
Practice Address - Fax:727-584-3102
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME90619208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
I12413Medicare UPIN