Provider Demographics
NPI:1407849722
Name:GORDON, STEPHANIE H (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:H
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 1:2750 OWENS RD SW
Mailing Address - Street 2:SUITE A
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-3991
Mailing Address - Country:US
Mailing Address - Phone:678-413-4644
Mailing Address - Fax:678-413-4624
Practice Address - Street 1:2750 OWENS RD SW
Practice Address - Street 2:SUITE A
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-3991
Practice Address - Country:US
Practice Address - Phone:678-413-4644
Practice Address - Fax:678-413-4624
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2012-08-06
Deactivation Date:2006-03-27
Deactivation Code:
Reactivation Date:2006-04-07
Provider Licenses
StateLicense IDTaxonomies
GA049382207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA551117710AMedicaid
GAH41568Medicare UPIN
GA16BBCDRMedicare PIN