Provider Demographics
NPI:1669024592
Name:GORDON DE JESUS, ADRIANA I
Entity Type:Individual
Prefix:
First Name:ADRIANA
Middle Name:I
Last Name:GORDON DE JESUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4968
Mailing Address - Street 2:
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00726-4968
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:BO MONACILLOS CARR #22
Practice Address - Street 2:
Practice Address - City:RIO PIEDRAS
Practice Address - State:PR
Practice Address - Zip Code:00935
Practice Address - Country:US
Practice Address - Phone:787-474-0333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-11
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR15447208000000X
PR22458208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics