Provider Demographics
NPI:1538108261
Name:GORDON, GLENN (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:
Last Name:GORDON
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 1:2073 OLYMPIC ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-3413
Mailing Address - Country:US
Mailing Address - Phone:541-682-3550
Mailing Address - Fax:
Practice Address - Street 1:2073 OLYMPIC ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477
Practice Address - Country:US
Practice Address - Phone:541-682-3550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD15934207P00000X, 207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR057141Medicaid
J0475-05OtherPACIFIC SOURCE
C89984OtherLIPA
76172OtherWASHINGTON L&I
057221003OtherBCBS
WA8280034Medicaid
A018OtherCHAMPUS
C89984OtherPROVIDENCE
C89984OtherGROUP HEALTH
CAXPY185053Medicaid
J0475-05OtherPACIFIC SOURCE
C89984OtherGROUP HEALTH
OR057141Medicaid
ORR174190Medicare PIN
057221003OtherBCBS
0000WFBBXMedicare PIN