Provider Demographics
NPI:1689644882
Name:GORDON, MICKEY E (DPM)
Entity Type:Individual
Prefix:DR
First Name:MICKEY
Middle Name:E
Last Name:GORDON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:9955 TAMIAMI TRL N
Mailing Address - Street 2:SUITE 1
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34108-1914
Mailing Address - Country:US
Mailing Address - Phone:239-566-8800
Mailing Address - Fax:239-566-8778
Practice Address - Street 1:9955 TAMIAMI TRL N
Practice Address - Street 2:SUITE 1
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34108-1914
Practice Address - Country:US
Practice Address - Phone:239-566-8800
Practice Address - Fax:239-566-8778
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2638213E00000X
MI0936213E00000X
NM187213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5782609OtherAETNA PROVIDER #
FL65543OtherBC/BS PROVIDER #
FLK6801OtherMEDICARE ID
MI0936OtherPODIATRIC MEDICAL LICENSE
NM187OtherPODIATRIC MEDICAL LICENSE
FLPO2638OtherPODIATRIC MEDICAL LICENSE
FLK6801OtherMEDICARE ID
FLT97329Medicare UPIN