Provider Demographics
NPI:1619132669
Name:BLAND, GORDON DAVID JR (IDC)
Entity Type:Individual
Prefix:MR
First Name:GORDON
Middle Name:DAVID
Last Name:BLAND
Suffix:JR
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:94 PLANT ST
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-4455
Mailing Address - Country:US
Mailing Address - Phone:860-694-3505
Mailing Address - Fax:860-694-4326
Practice Address - Street 1:NAVAL SUBMARINE BASE NEW LONDON
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:06349-5000
Practice Address - Country:US
Practice Address - Phone:860-694-3505
Practice Address - Fax:860-694-4326
Is Sole Proprietor?:No
Enumeration Date:2008-07-18
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman