Provider Demographics
NPI:1346421203
Name:JOEL P GORDON MD PA
Entity Type:Organization
Organization Name:JOEL P GORDON MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ITA
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-585-8183
Mailing Address - Street 1:424 S COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:LANTANA
Mailing Address - State:FL
Mailing Address - Zip Code:33462-1204
Mailing Address - Country:US
Mailing Address - Phone:561-585-8183
Mailing Address - Fax:561-383-2997
Practice Address - Street 1:424 S COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:LANTANA
Practice Address - State:FL
Practice Address - Zip Code:33462-1204
Practice Address - Country:US
Practice Address - Phone:561-585-8183
Practice Address - Fax:561-383-2997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-20
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME19252302R00000X, 305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
No305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD55780Medicare UPIN
FL50668Medicare PIN