Provider Demographics
NPI:1275560831
Name:GORDON, PAUL R (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:R
Last Name:GORDON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:PAUL
Other - Middle Name:R
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 191
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPARTMENT,
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-6718
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:1717 S ORANGE AVE STE 100
Practice Address - Street 2:NEMOURS CHILDRENS CLINIC, ORLANDO,
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2946
Practice Address - Country:US
Practice Address - Phone:407-650-7000
Practice Address - Fax:407-567-5924
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME880112080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2677831-00Medicaid
FL267783100Medicaid
FL267783100Medicaid
FLH97169Medicare UPIN
FL81550Medicare PIN
FL2677831-00Medicaid