Provider Demographics
NPI:1568745677
Name:GORDON, PETER F (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:F
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:AVENIDA LOS TULES 116, INT 14
Mailing Address - Street 2:COLONIA DIAZ ORDAZ
Mailing Address - City:PUERTO VALLARTA
Mailing Address - State:JALISCO
Mailing Address - Zip Code:48310
Mailing Address - Country:MX
Mailing Address - Phone:322-293-1552
Mailing Address - Fax:
Practice Address - Street 1:AVENIDA LOS TULES 116, INT 14
Practice Address - Street 2:COLONIA DIAZ ORDAZ
Practice Address - City:PUERTO VALLARTA
Practice Address - State:JALISCO
Practice Address - Zip Code:48310
Practice Address - Country:MX
Practice Address - Phone:322-293-1552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-25
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301407657207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine