Provider Demographics
NPI:1558367490
Name:GORDON, RICHARD JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:JOSEPH
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:PO BOX 33269
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85067-3269
Mailing Address - Country:US
Mailing Address - Phone:602-406-4786
Mailing Address - Fax:916-636-4358
Practice Address - Street 1:500 W THOMAS RD STE 480
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4239
Practice Address - Country:US
Practice Address - Phone:602-406-1150
Practice Address - Fax:602-406-1159
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18785207RC0000X
TN39181207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3730779Medicaid
TN1558367490Medicare PIN
E89605Medicare UPIN