Provider Demographics
NPI:1326133323
Name:GORDON, MARTIN A
Entity Type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:A
Last Name:GORDON
Suffix:
Gender:M
Credentials:
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 529
Mailing Address - Street 2:
Mailing Address - City:BAYFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54814-0529
Mailing Address - Country:US
Mailing Address - Phone:715-779-3707
Mailing Address - Fax:715-779-3711
Practice Address - Street 1:37390 N BRADUM RD
Practice Address - Street 2:
Practice Address - City:BAYFIELD
Practice Address - State:WI
Practice Address - Zip Code:54814-4832
Practice Address - Country:US
Practice Address - Phone:715-779-3741
Practice Address - Fax:715-779-3765
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11815101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39372600Medicaid