Provider Demographics
NPI:1376500223
Name:GORDON, DAVID LEE (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:LEE
Last Name:GORDON
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 1:711 STANTON L YOUNG BLVD
Mailing Address - Street 2:SUITE 215
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104
Mailing Address - Country:US
Mailing Address - Phone:405-271-4113
Mailing Address - Fax:405-271-5723
Practice Address - Street 1:711 STANTON L YOUNG BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5021
Practice Address - Country:US
Practice Address - Phone:405-271-3635
Practice Address - Fax:405-271-2523
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME802552084N0400X, 2084V0102X
OK254342084N0400X, 2084V0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL259420000Medicaid
FL259420000Medicaid
FL35288Medicare ID - Type Unspecified