Provider Demographics
NPI:1437151370
Name:GORDON, KEVIN J (DO)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:J
Last Name:GORDON
Suffix:
Gender:M
Credentials:DO
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 1610
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74702-1610
Mailing Address - Country:US
Mailing Address - Phone:580-924-3400
Mailing Address - Fax:580-924-7732
Practice Address - Street 1:1610 W UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-3045
Practice Address - Country:US
Practice Address - Phone:580-924-3400
Practice Address - Fax:580-924-7732
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4127207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200048780AMedicaid