Provider Demographics
NPI:1346392602
Name:GORDON, NATHAN L (DO)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:L
Last Name:GORDON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19231 BERKELEY RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-1867
Mailing Address - Country:US
Mailing Address - Phone:313-345-7888
Mailing Address - Fax:
Practice Address - Street 1:111 S GRANT
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MI
Practice Address - Zip Code:48214-3707
Practice Address - Country:US
Practice Address - Phone:614-566-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101005592207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4181835-11Medicaid
MI5558242OtherAETNA
MI0Q26056015Medicare ID - Type Unspecified
MI5558242OtherAETNA
MI050074023Medicare ID - Type UnspecifiedRAILROAD