Provider Demographics
NPI:1578856241
Name:BURKE, GORDON M (MD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:M
Last Name:BURKE
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 1:720 HARRISON AVE
Mailing Address - Street 2:DOB 503
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2371
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 VFW PARKWAY
Practice Address - Street 2:CARDIOLOGY SECTION 111CA
Practice Address - City:WEST ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02132
Practice Address - Country:US
Practice Address - Phone:857-203-6840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-27
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA260120207R00000X, 207RC0000X
MA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program