Provider Demographics
NPI:1558666560
Name:GORDON, JAMES OTIS (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:OTIS
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 538
Mailing Address - Street 2:
Mailing Address - City:FAIRHOPE
Mailing Address - State:AL
Mailing Address - Zip Code:36533-0538
Mailing Address - Country:US
Mailing Address - Phone:251-928-0611
Mailing Address - Fax:
Practice Address - Street 1:210 S MOBILE ST
Practice Address - Street 2:#23
Practice Address - City:FAIRHOPE
Practice Address - State:AL
Practice Address - Zip Code:36532-1365
Practice Address - Country:US
Practice Address - Phone:251-928-0611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-22
Last Update Date:2011-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS05557208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology