Provider Demographics
NPI:1326000670
Name:ENNS, GORDON (MD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:
Last Name:ENNS
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:PO BOX 4749
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-0227
Mailing Address - Country:US
Mailing Address - Phone:541-789-5516
Mailing Address - Fax:541-789-5538
Practice Address - Street 1:280 MAPLE ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-1552
Practice Address - Country:US
Practice Address - Phone:541-201-4000
Practice Address - Fax:541-488-7434
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD10734207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C91177OtherGROUP HEALTH
OR235101Medicaid
C91177OtherPROVIDENCE HEALTH PLANS
OR023507000OtherBLUE CROSS BLUE SHIELD
930079056OtherRAILROAD MEDICARE
XPY185046OtherMEDI - CAL
97520A009OtherCHAMPUS
R104098Medicare PIN
97520A009OtherCHAMPUS