Provider Demographics
NPI:1679849640
Name:GORDON, LEAH MACKE (MD)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:MACKE
Last Name:GORDON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 RAILROAD ST W
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-4109
Mailing Address - Country:US
Mailing Address - Phone:406-258-4789
Mailing Address - Fax:
Practice Address - Street 1:401 RAILROAD ST W
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4109
Practice Address - Country:US
Practice Address - Phone:406-258-4789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-23
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-PHYS-LIC-102284207R00000X
WAMD50662894207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1679849640Medicaid
PENDINGMedicare PIN