Provider Demographics
NPI:1417984303
Name:VOGEL, GORDON A (MD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:A
Last Name:VOGEL
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 717
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IN
Mailing Address - Zip Code:47620-0717
Mailing Address - Country:US
Mailing Address - Phone:812-838-4891
Mailing Address - Fax:812-838-6595
Practice Address - Street 1:1900 W 4TH ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IN
Practice Address - Zip Code:47620-9407
Practice Address - Country:US
Practice Address - Phone:812-838-4891
Practice Address - Fax:812-838-6595
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01028250207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100210130AMedicaid
IN100210130AMedicaid
660470Medicare ID - Type Unspecified