Provider Demographics
NPI:1619954088
Name:LAIRD, GORDON P (DO)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:P
Last Name:LAIRD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:534 ILLINOIS ST
Mailing Address - Street 2:
Mailing Address - City:PAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74058-2036
Mailing Address - Country:US
Mailing Address - Phone:918-762-3602
Mailing Address - Fax:918-762-2952
Practice Address - Street 1:304 BOULDER ST
Practice Address - Street 2:
Practice Address - City:PAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74058-4028
Practice Address - Country:US
Practice Address - Phone:918-762-3601
Practice Address - Fax:918-762-2544
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-28
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1532208600000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100128350BMedicaid