Provider Demographics
NPI:1386668879
Name:GORDIN, STEPHEN JACOB (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:JACOB
Last Name:GORDIN
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:PO BOX 52990
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29649-0048
Mailing Address - Country:US
Mailing Address - Phone:864-223-3600
Mailing Address - Fax:864-223-6054
Practice Address - Street 1:225 STABLE GATE DR
Practice Address - Street 2:
Practice Address - City:CAMPOBELLO
Practice Address - State:SC
Practice Address - Zip Code:29322-8037
Practice Address - Country:US
Practice Address - Phone:864-468-5570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC165662085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC165662Medicaid
SCE98899Medicare UPIN
SC165662Medicaid