Provider Demographics
NPI:1639105794
Name:GORDON, GREGORY ANDREW (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:ANDREW
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 1:232 MARKET ST
Mailing Address - Street 2:SUITE 234
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-3339
Mailing Address - Country:US
Mailing Address - Phone:601-214-3539
Mailing Address - Fax:601-914-7201
Practice Address - Street 1:232 MARKET ST
Practice Address - Street 2:SUITE 234
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-3339
Practice Address - Country:US
Practice Address - Phone:601-214-3539
Practice Address - Fax:601-914-7201
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-23
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS163912084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL179088Medicaid
MS00120813Medicaid
MS260044396OtherRAILROAD MEDICARE
MSP00657494OtherMEDICARE RR
MS512I260022Medicare PIN
MS260044396OtherRAILROAD MEDICARE
AL179088Medicaid
MS260000444Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER