Provider Demographics
NPI:1679580906
Name:GORDON, JAMES KENNER SR (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:KENNER
Last Name:GORDON
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1219 EAST AVE
Mailing Address - Street 2:STE 308
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239-2348
Mailing Address - Country:US
Mailing Address - Phone:941-366-4015
Mailing Address - Fax:941-366-4125
Practice Address - Street 1:1219 EAST AVE
Practice Address - Street 2:STE 308
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-2348
Practice Address - Country:US
Practice Address - Phone:941-366-4015
Practice Address - Fax:941-366-4125
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2009-10-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME0015938207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL058750800Medicaid
FLD62249Medicare UPIN
FL31097Medicare ID - Type UnspecifiedFLORIDA MEDICARE ID