Provider Demographics
NPI:1609972298
Name:NIDIFFER, GORDON G (MD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:G
Last Name:NIDIFFER
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:PO BOX 517
Mailing Address - Street 2:
Mailing Address - City:BOCA GRRANDE
Mailing Address - State:FL
Mailing Address - Zip Code:33921
Mailing Address - Country:US
Mailing Address - Phone:941-964-2276
Mailing Address - Fax:941-964-2075
Practice Address - Street 1:320 PARK AVENUE
Practice Address - Street 2:
Practice Address - City:BOCA GRANDE
Practice Address - State:FL
Practice Address - Zip Code:33921
Practice Address - Country:US
Practice Address - Phone:941-964-2276
Practice Address - Fax:941-964-2075
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME31227207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0031227OtherME
0031227OtherME
0031227OtherME
FL79444YMedicare ID - Type Unspecified