Provider Demographics
NPI:1629008552
Name:MOSHMAN, GORDON S (MD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:S
Last Name:MOSHMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:4242 FARNAM ST
Mailing Address - Street 2:#150
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68131-2806
Mailing Address - Country:US
Mailing Address - Phone:402-552-6747
Mailing Address - Fax:402-552-6741
Practice Address - Street 1:2727 S 144TH ST
Practice Address - Street 2:#280
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-5225
Practice Address - Country:US
Practice Address - Phone:402-778-5490
Practice Address - Fax:402-778-5499
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NE14949207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10024982500Medicaid
NE10024982500Medicaid
NE279617Medicare ID - Type Unspecified