Provider Demographics
NPI:1659082964
Name:GORDON, DUSTIN (DC)
Entity Type:Individual
Prefix:DR
First Name:DUSTIN
Middle Name:
Last Name:GORDON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11515 W 91ST ST S
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066-8422
Mailing Address - Country:US
Mailing Address - Phone:918-691-6885
Mailing Address - Fax:
Practice Address - Street 1:609 E MAIN ST
Practice Address - Street 2:
Practice Address - City:JENKS
Practice Address - State:OK
Practice Address - Zip Code:74037-4138
Practice Address - Country:US
Practice Address - Phone:918-299-1296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-07
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4515111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor