Provider Demographics
NPI:1407874290
Name:AVERY, GORDON L (MD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:L
Last Name:AVERY
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 75868
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21275-5868
Mailing Address - Country:US
Mailing Address - Phone:703-383-6469
Mailing Address - Fax:
Practice Address - Street 1:1635 N GEORGE MASON DR
Practice Address - Street 2:SUITE 310
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22205-3616
Practice Address - Country:US
Practice Address - Phone:703-810-5215
Practice Address - Fax:703-810-5428
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101031957207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6404880Medicaid
P00151206OtherMEDICARE RAILROAD
0962280007Medicare NSC
538695Medicare PIN
P00151206OtherMEDICARE RAILROAD
DC1555Medicare PIN
B93973Medicare UPIN
0962280002Medicare NSC