Provider Demographics
NPI:1497536387
Name:GORDON, OSCAR JR
Entity Type:Individual
Prefix:MR
First Name:OSCAR
Middle Name:
Last Name:GORDON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4426 HUGH HOWELL RD # 117
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-4918
Mailing Address - Country:US
Mailing Address - Phone:678-383-7279
Mailing Address - Fax:
Practice Address - Street 1:2457 DAKOTA TRL SW
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-5772
Practice Address - Country:US
Practice Address - Phone:678-531-1232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-09
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171400000X
GAMT009326225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No171400000XOther Service ProvidersHealth & Wellness Coach