Provider Demographics
NPI:1588604581
Name:GORDON, ROBERT T (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:T
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 1:4150 5TH ST
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-6022
Mailing Address - Country:US
Mailing Address - Phone:605-399-4300
Mailing Address - Fax:605-399-4352
Practice Address - Street 1:4150 5TH ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-6022
Practice Address - Country:US
Practice Address - Phone:605-399-4300
Practice Address - Fax:605-399-4352
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD5310208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD060031670OtherRAILROAD MEDICARE
SD4995658OtherBLUE CROSS OF SD
SD7301930Medicaid
SD41638Medicare ID - Type Unspecified