Provider Demographics
NPI:1467446542
Name:GORDON, BRUCE RODERICK (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:RODERICK
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 1:65 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:HYANNIS
Mailing Address - State:MA
Mailing Address - Zip Code:02601-3009
Mailing Address - Country:US
Mailing Address - Phone:508-790-0611
Mailing Address - Fax:508-790-0589
Practice Address - Street 1:65 CEDAR ST
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601-3009
Practice Address - Country:US
Practice Address - Phone:508-790-0611
Practice Address - Fax:508-790-0589
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA47040207Y00000X, 207YX0602X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic Allergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0142514Medicaid
MABX8521Medicare PIN
MA0142514Medicaid