Provider Demographics
NPI:1568460483
Name:GORDON, JONATHAN K (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:K
Last Name:GORDON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 AMESBURY ST
Mailing Address - Street 2:SUITE 113
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01840-1321
Mailing Address - Country:US
Mailing Address - Phone:978-685-5474
Mailing Address - Fax:978-689-0493
Practice Address - Street 1:100 AMESBURY ST
Practice Address - Street 2:SUITE 113
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01840-1321
Practice Address - Country:US
Practice Address - Phone:978-685-5474
Practice Address - Fax:978-689-0493
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-13
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA79322208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3188396Medicaid
A29003Medicare PIN
G83565Medicare UPIN