Provider Demographics
NPI:1235368945
Name:GORDON, LONNA (MD, PHARM D)
Entity Type:Individual
Prefix:DR
First Name:LONNA
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:MD, PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10140 CENTURION PKWY N FL PROVIDER
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-0532
Mailing Address - Country:US
Mailing Address - Phone:904-697-3600
Mailing Address - Fax:
Practice Address - Street 1:13535 NEMOURS PKWY
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32827
Practice Address - Country:US
Practice Address - Phone:407-567-4000
Practice Address - Fax:407-567-5924
Is Sole Proprietor?:No
Enumeration Date:2009-07-02
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME135539208000000X, 2080A0000X
DEC1-0013322208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL024920900Medicaid