Provider Demographics
NPI:1548234255
Name:WUEBBOLT, GORDON EDGAR (MD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:EDGAR
Last Name:WUEBBOLT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:GORDON
Other - Middle Name:EDGAR
Other - Last Name:WUEBBOLT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2 FARM COLONY DRIVE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:PA
Mailing Address - Zip Code:16365-5206
Mailing Address - Country:US
Mailing Address - Phone:814-726-2303
Mailing Address - Fax:814-726-7459
Practice Address - Street 1:2 FARM COLONY DRIVE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:PA
Practice Address - Zip Code:16365-5206
Practice Address - Country:US
Practice Address - Phone:814-726-2303
Practice Address - Fax:814-726-7459
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-17
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD052930L156FX1100X, 207WX0200X, 207W00000X
NY219642-1156FX1100X, 207W00000X, 207WX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No156FX1100XEye and Vision Services ProvidersTechnician/TechnologistOphthalmic
No207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001464588Medicaid
NY02155728Medicaid
NYCC4926OtherMEDICARE NUMBER
PA0014645880011Medicaid
NY02155728Medicaid
NY02155728OtherMEDICAID NUMBER
PA0014645880014Medicaid
PAF34988Medicare UPIN
PA0014645880014Medicaid
PA0014645880014Medicaid