Provider Demographics
NPI:1558334771
Name:GORDON, DAVID ALAN (AT)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:ALAN
Last Name:GORDON
Suffix:
Gender:M
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3407 S HALL AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-4800
Mailing Address - Country:US
Mailing Address - Phone:417-890-1354
Mailing Address - Fax:
Practice Address - Street 1:1500 N OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-3011
Practice Address - Country:US
Practice Address - Phone:417-777-7763
Practice Address - Fax:417-777-4378
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO001402255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer