Provider Demographics
NPI:1497752208
Name:GORDON, KENNETH BRYCE (OD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:BRYCE
Last Name:GORDON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4811 S LABURNUM AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23231-2713
Mailing Address - Country:US
Mailing Address - Phone:804-226-1144
Mailing Address - Fax:804-236-9026
Practice Address - Street 1:4811 S LABURNUM AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23231-2713
Practice Address - Country:US
Practice Address - Phone:804-226-1144
Practice Address - Fax:804-236-9026
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000495152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VADA5536OtherRAILROAD MEDICARE PIN
VAU84594OtherRAILROAD MEDICARE UPIN
VA541783118OtherRAILROAD MEDICARE TAX ID
VA9232362Medicaid
541783118OtherMEDICARE TAX ID
VAP00068065OtherRAILROAD PROVIDER
VAP00068065OtherRAILROAD PROVIDER
VAU84594Medicare UPIN