Provider Demographics
NPI:1619959269
Name:GORDON, BERKMAN O (MD)
Entity Type:Individual
Prefix:DR
First Name:BERKMAN
Middle Name:O
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 1:1609 N ANKENY BLVD
Mailing Address - Street 2:200
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50023-4165
Mailing Address - Country:US
Mailing Address - Phone:404-822-0871
Mailing Address - Fax:
Practice Address - Street 1:1609 N ANKENY BLVD
Practice Address - Street 2:200
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023-4165
Practice Address - Country:US
Practice Address - Phone:404-822-0871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA37815207P00000X, 207Q00000X, 207U00000X
IL036091223207P00000X
IL036.091223207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF74509Medicare UPIN