Provider Demographics
NPI:1689622961
Name:GORDON, BRUCE G (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:G
Last Name:GORDON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:988102 NEBRASKA MEDICAL CTR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68198-8102
Mailing Address - Country:US
Mailing Address - Phone:402-559-7257
Mailing Address - Fax:402-559-6782
Practice Address - Street 1:988102 NEBRASKA MEDICAL CTR
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68198-8102
Practice Address - Country:US
Practice Address - Phone:402-559-7257
Practice Address - Fax:402-559-6782
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NE175342080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE17534OtherNE LICENSE