Provider Demographics
NPI:1629180179
Name:GORDON, KIMBERLY L (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:L
Last Name:GORDON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:L
Other - Last Name:HAYES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:682-885-1396
Practice Address - Street 1:801 7TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2733
Practice Address - Country:US
Practice Address - Phone:682-885-4095
Practice Address - Fax:682-885-7499
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ8556207PP0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00L42VOtherBCBSTX GRP PIN
TX5319555OtherAETNA PIN
TX118151305OtherCSHCN
TX88626XOtherBCBSTX IND PIN
TX10025757OtherAMERIGROUP PIN
TX137573100OtherFIRSTCARE PIN
TX107491OtherSUPERIOR PIN
TX11071765OtherFIRSTHEALTH PIN
TX9053250OtherPHCS PIN
TX118151304Medicaid
1669442042OtherGRP NPI NUMBER
TX1930160OtherUHC PIN
TX2904477OtherCIGNA PIN
TX10025757OtherAMERIGROUP PIN
TX5319555OtherAETNA PIN
TX88626XOtherBCBSTX IND PIN