Provider Demographics
NPI:1508902727
Name:GORDON, CAMERON
Entity Type:Individual
Prefix:
First Name:CAMERON
Middle Name:
Last Name:GORDON
Suffix:
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 1:4174 INVERRARY DR APT 611
Mailing Address - Street 2:
Mailing Address - City:LAUDERHILL
Mailing Address - State:FL
Mailing Address - Zip Code:33319-4572
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:660 GLADES ROAD
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-6465
Practice Address - Country:US
Practice Address - Phone:561-391-5515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT22974225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL22974OtherLICENSE#
FL22974OtherLICENSE#