Provider Demographics
NPI:1679849780
Name:GORDON, SHAYNA LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAYNA
Middle Name:LEE
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 1:111 NEW HAMPSHIRE AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-2864
Mailing Address - Country:US
Mailing Address - Phone:802-909-2053
Mailing Address - Fax:
Practice Address - Street 1:824 EDWARDS DR
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IN
Practice Address - Zip Code:46168-2791
Practice Address - Country:US
Practice Address - Phone:317-406-3254
Practice Address - Fax:317-406-3259
Is Sole Proprietor?:No
Enumeration Date:2012-03-23
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01078403A207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery