Provider Demographics
NPI:1386678688
Name:GORDON, CHRISANNE (MD)
Entity Type:Individual
Prefix:
First Name:CHRISANNE
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 LONDON AVE
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-1515
Mailing Address - Country:US
Mailing Address - Phone:937-578-2255
Mailing Address - Fax:937-578-2268
Practice Address - Street 1:660 LONDON AVE
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040-1515
Practice Address - Country:US
Practice Address - Phone:937-578-2255
Practice Address - Fax:937-578-2268
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-04-2915225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000119248OtherANTHEM
OH0707328Medicaid
OHC01641Medicare UPIN
OH0707328Medicaid