Provider Demographics
NPI:1326054263
Name:HASKELL, GORDON ALEXANDER (MD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:ALEXANDER
Last Name:HASKELL
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 1:3141 NW 63RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73116
Mailing Address - Country:US
Mailing Address - Phone:405-607-1318
Mailing Address - Fax:405-607-1326
Practice Address - Street 1:549 E FAIR ST
Practice Address - Street 2:BLOOMBURG HOSPITAL
Practice Address - City:BLOOMSBURG
Practice Address - State:PA
Practice Address - Zip Code:17815
Practice Address - Country:US
Practice Address - Phone:717-387-2115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD37149E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA50060527OtherCAPITAL BLUE CROSS
PAHA40669OtherHIGHMARK BLUE SHIELD
PA0011180410002Medicaid
PA50060527OtherCAPITAL BLUE CROSS
PA0011180410002Medicaid