Provider Demographics
NPI:1427018613
Name:GORDON, MAXIE LERONE (MD)
Entity Type:Individual
Prefix:DR
First Name:MAXIE
Middle Name:LERONE
Last Name:GORDON
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 1:590 SPRINGRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-5606
Mailing Address - Country:US
Mailing Address - Phone:601-488-8101
Mailing Address - Fax:866-499-2129
Practice Address - Street 1:590 SPRINGRIDGE RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-5606
Practice Address - Country:US
Practice Address - Phone:601-488-8101
Practice Address - Fax:866-499-2129
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS98012882084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08723392Medicaid
MI9014277Medicaid
MI9014277Medicaid
MI9014277Medicaid
MI08723392Medicaid
MS260000596Medicare PIN