Provider Demographics
NPI:1518917301
Name:GORDON, GREGORY A (DO)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:A
Last Name:GORDON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 SOUTHERN BLVD STE 401
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-1226
Mailing Address - Country:US
Mailing Address - Phone:855-500-2873
Mailing Address - Fax:937-281-3913
Practice Address - Street 1:3700 SOUTHERN BLVD STE 401
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1226
Practice Address - Country:US
Practice Address - Phone:855-500-2873
Practice Address - Fax:937-281-3913
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34004894207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0948925Medicaid
OH0948925Medicaid
OH0738456Medicare PIN
OHF55958Medicare PIN