Provider Demographics
NPI:1659789964
Name:CHARLES R GORDON, MD, PA
Entity Type:Organization
Organization Name:CHARLES R GORDON, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:036-531-8239
Mailing Address - Street 1:PO BOX 6605
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75711-6605
Mailing Address - Country:US
Mailing Address - Phone:903-363-1550
Mailing Address - Fax:903-595-1592
Practice Address - Street 1:5016 GILMER RD
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75604-9666
Practice Address - Country:US
Practice Address - Phone:903-653-1823
Practice Address - Fax:903-653-1822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-30
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00805VMedicare PIN