Provider Demographics
NPI:1659353993
Name:GORDON, PHILLIP C (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:C
Last Name:GORDON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 144333
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32814-4333
Mailing Address - Country:US
Mailing Address - Phone:407-422-9831
Mailing Address - Fax:407-648-2065
Practice Address - Street 1:200 AVENUE F NE
Practice Address - Street 2:DEPT. OF PATHOLOGY
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-4131
Practice Address - Country:US
Practice Address - Phone:863-293-1121
Practice Address - Fax:863-291-6071
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2007-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME31515207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D56613Medicare UPIN
FL53631YMedicare PIN