Provider Demographics
NPI:1538141858
Name:FALL, GORDON FF (MD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:FF
Last Name:FALL
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 1:7715 24TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98117-4412
Mailing Address - Country:US
Mailing Address - Phone:206-782-1133
Mailing Address - Fax:206-782-1373
Practice Address - Street 1:7715 24TH AVE NW
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98117-4412
Practice Address - Country:US
Practice Address - Phone:206-782-1133
Practice Address - Fax:206-782-1373
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00009179207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1254507Medicaid
WAA04452Medicare UPIN
WAAB00699Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER