Provider Demographics
NPI:1598723934
Name:GORDON, SCOTT DAVID (OD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:DAVID
Last Name:GORDON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 E LEE AVE
Mailing Address - Street 2:
Mailing Address - City:YADKINVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27055-8227
Mailing Address - Country:US
Mailing Address - Phone:336-679-2931
Mailing Address - Fax:336-677-6486
Practice Address - Street 1:225 E LEE AVE
Practice Address - Street 2:
Practice Address - City:YADKINVILLE
Practice Address - State:NC
Practice Address - Zip Code:27055
Practice Address - Country:US
Practice Address - Phone:336-679-2931
Practice Address - Fax:336-677-6486
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1999152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
2474038COtherMEDICARE - YADKINVILLE
525320OtherOE TRACKER
1598723934OtherNPI
NC1999OtherOD LICENSE
2474038DOtherMEDICARE - EAST BEND
NC5908096Medicaid
NC5908096Medicaid
V09424Medicare UPIN