Provider Demographics
NPI:1275528887
Name:GORDON, MARK R (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:R
Last Name:GORDON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 12868
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33733-2868
Mailing Address - Country:US
Mailing Address - Phone:727-532-1355
Mailing Address - Fax:727-266-4928
Practice Address - Street 1:620 10TH STREET N.
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33705-1407
Practice Address - Country:US
Practice Address - Phone:727-824-7146
Practice Address - Fax:727-824-7119
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2014-03-31
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME20691208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL058923300Medicaid
FL058923300Medicaid
FL52959YMedicare PIN