Provider Demographics
NPI:1437240199
Name:GORDON, ROSEMARIE ROQUE (MD)
Entity Type:Individual
Prefix:
First Name:ROSEMARIE
Middle Name:ROQUE
Last Name:GORDON
Suffix:
Gender:F
Credentials:MD
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Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:ONE BOSTON MEDICAL CENTER PLACE
Mailing Address - Street 2:DIVISION OF PEDIATRICS DOWLING 3 SOUTH
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118
Mailing Address - Country:US
Mailing Address - Phone:617-414-5170
Mailing Address - Fax:617-414-3803
Practice Address - Street 1:ONE BOSTON MEDICAL CENTER PLACE
Practice Address - Street 2:CHILD HEALTH FOUNDATION OF BOSTON DOWLING 3 SOUTH
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118
Practice Address - Country:US
Practice Address - Phone:617-414-5170
Practice Address - Fax:617-414-3803
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA226695208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2119285Medicaid