Provider Demographics
NPI:1659455756
Name:GARY M GORDON DPM PC
Entity Type:Organization
Organization Name:GARY M GORDON DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:215-887-5910
Mailing Address - Street 1:2285 CROSS RD
Mailing Address - Street 2:
Mailing Address - City:GLENSIDE
Mailing Address - State:PA
Mailing Address - Zip Code:19038
Mailing Address - Country:US
Mailing Address - Phone:215-887-5910
Mailing Address - Fax:215-887-0387
Practice Address - Street 1:2285 CROSS RD
Practice Address - Street 2:
Practice Address - City:GLENSIDE
Practice Address - State:PA
Practice Address - Zip Code:19038
Practice Address - Country:US
Practice Address - Phone:215-887-5910
Practice Address - Fax:215-887-0387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC00L57L213ES0103X
PASC001507L332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1991OtherAETNA HMO
0060635000OtherKEYSTONE
0000118918OtherPA BLUE SHIELD
0060635000OtherPERSONAL CHOICE
7305038OtherAETNA
0000118918OtherPA BLUE SHIELD
0060635000OtherPERSONAL CHOICE
1991OtherAETNA HMO