Provider Demographics
NPI:1629177068
Name:JENSEN, GORDON L (MD, PHD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:L
Last Name:JENSEN
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 COLCHESTER AVENUE
Mailing Address - Street 2:UVM MEDICAL CENTER, DEPT. OF MEDICINE
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401
Mailing Address - Country:US
Mailing Address - Phone:802-847-8865
Mailing Address - Fax:802-847-7082
Practice Address - Street 1:111 COLCHESTER AVENUE
Practice Address - Street 2:UVM MEDICAL CENTER, DEPT. OF MEDICINE
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401
Practice Address - Country:US
Practice Address - Phone:802-847-8865
Practice Address - Fax:802-847-7082
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD041176E207R00000X
VT042.0013293207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine