Provider Demographics
NPI:1548571060
Name:GORDON, DIANDRA KAREEN (DPM)
Entity Type:Individual
Prefix:DR
First Name:DIANDRA
Middle Name:KAREEN
Last Name:GORDON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1629 REDSTONE CT
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-5028
Mailing Address - Country:US
Mailing Address - Phone:904-389-0346
Mailing Address - Fax:904-246-5449
Practice Address - Street 1:1126 UNIVERSITY BLVD N
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211-8850
Practice Address - Country:US
Practice Address - Phone:904-765-5554
Practice Address - Fax:904-765-9302
Is Sole Proprietor?:No
Enumeration Date:2010-06-30
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3624213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103938700Medicaid