Provider Demographics
NPI:1497729933
Name:FIFER, GORDON LUCAS (MD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:LUCAS
Last Name:FIFER
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 1:3001 GREEN BAY RD
Mailing Address - Street 2:CAPTAIN JAMES A. LOVELL FEDERAL HEALTH CARE CENTER
Mailing Address - City:NORTH CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60064-3048
Mailing Address - Country:US
Mailing Address - Phone:226-610-8102
Mailing Address - Fax:
Practice Address - Street 1:3001 GREEN BAY RD
Practice Address - Street 2:CAPTAIN JAMES A. LOVELL FEDERAL HEALTH CARE CENTER
Practice Address - City:NORTH CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60064-3048
Practice Address - Country:US
Practice Address - Phone:226-610-8102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAM.D.202048208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology