Provider Demographics
NPI:1437101508
Name:THEISZ, GORDON W (MD)
Entity type:Individual
Prefix:
First Name:GORDON
Middle Name:W
Last Name:THEISZ
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 1:825 FAIRFAX AVE # 118
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-1914
Mailing Address - Country:US
Mailing Address - Phone:757-446-5955
Mailing Address - Fax:
Practice Address - Street 1:825 FAIRFAX AVE # 118
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1912
Practice Address - Country:US
Practice Address - Phone:757-446-5955
Practice Address - Fax:757-446-5196
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2025-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101102617207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP00377886OtherRAILROAD MEDICARE
VA010189781Medicaid
VAP00377886OtherRAILROAD MEDICARE
VAH47850Medicare UPIN
VAG02125F01Medicare ID - Type UnspecifiedPRIVATE PRACTICE #