Provider Demographics
NPI:1376512152
Name:GORDON, BRENT (DO)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:GORDON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3629 WESTERN CENTER BLVD
Mailing Address - Street 2:STE. 211
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-1939
Mailing Address - Country:US
Mailing Address - Phone:817-232-9115
Mailing Address - Fax:817-232-9130
Practice Address - Street 1:3629 WESTERN CENTER BLVD
Practice Address - Street 2:STE. 211
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76137-1939
Practice Address - Country:US
Practice Address - Phone:817-232-9115
Practice Address - Fax:817-232-9130
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXH7558207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8J9054OtherBCBS
TX131610106Medicaid
TXP00281271OtherRAILROAD MEDICARE
TXE59796Medicare UPIN
TX8D9272Medicare PIN