Provider Demographics
NPI:1629369848
Name:GORDON, EDWARD S (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:S
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 1:105 BEECH CT
Mailing Address - Street 2:
Mailing Address - City:HUDSON OAKS
Mailing Address - State:TX
Mailing Address - Zip Code:76087-9447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 BEECH CT
Practice Address - Street 2:
Practice Address - City:HUDSON OAKS
Practice Address - State:TX
Practice Address - Zip Code:76087-9447
Practice Address - Country:US
Practice Address - Phone:630-852-9993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-21
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01050060A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine