Provider Demographics
NPI:1609980515
Name:GORDON, BERNARD J (MD)
Entity Type:Individual
Prefix:
First Name:BERNARD
Middle Name:J
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 1:145 NEWBURY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-4261
Mailing Address - Country:US
Mailing Address - Phone:207-772-5400
Mailing Address - Fax:207-772-5402
Practice Address - Street 1:145 NEWBURY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-4261
Practice Address - Country:US
Practice Address - Phone:207-772-5400
Practice Address - Fax:207-772-5402
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD118392084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME022314OtherANTHEM BLUE CROSS
MEE400171784Medicare PIN
MEMM078001Medicare PIN
MEMM0780Medicare PIN