Provider Demographics
NPI:1588663413
Name:GORDON, ROBERT (DO)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:GORDON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:965 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-2048
Mailing Address - Country:US
Mailing Address - Phone:734-455-2970
Mailing Address - Fax:313-561-0277
Practice Address - Street 1:965 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-2048
Practice Address - Country:US
Practice Address - Phone:734-455-2970
Practice Address - Fax:313-561-0277
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRG008180207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIE26587Medicare UPIN
MION76680001Medicare ID - Type Unspecified