Provider Demographics
NPI:1609873397
Name:GORTON, STEVEN J (MD)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:J
Last Name:GORTON
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 1:4525 3RD AVE SE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-1010
Mailing Address - Country:US
Mailing Address - Phone:360-754-3934
Mailing Address - Fax:360-412-8954
Practice Address - Street 1:4525 3RD AVE SE
Practice Address - Street 2:SUITE 200
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-1010
Practice Address - Country:US
Practice Address - Phone:360-754-3934
Practice Address - Fax:360-412-8954
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00020267174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1029263Medicaid
WAA08185Medicare UPIN
WA1029263Medicaid