Provider Demographics
NPI:1457314288
Name:GORDON, O T JR (MD)
Entity Type:Individual
Prefix:
First Name:O
Middle Name:T
Last Name:GORDON
Suffix:JR
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 1:1609 W 40TH AVE
Mailing Address - Street 2:SUITE 312
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-6329
Mailing Address - Country:US
Mailing Address - Phone:870-534-3344
Mailing Address - Fax:870-534-3517
Practice Address - Street 1:1609 W 40TH AVE
Practice Address - Street 2:SUITE 312
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-6329
Practice Address - Country:US
Practice Address - Phone:870-534-3344
Practice Address - Fax:870-534-3517
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC5353207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR152438001Medicaid
AR4198220OtherAETNA
AR2900041OtherUNITED HEALTH CARE
ARP00092540OtherRAIL ROAD MEDICARE
AR5M782OtherBLUE CROSS BLUE SHIELD
AR03120019200OtherQUALCHOICE
AR152438001Medicaid
5M782C989Medicare PIN
AR2900041OtherUNITED HEALTH CARE