Provider Demographics
NPI:1689675449
Name:GORDON, GARY M (DPM)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:M
Last Name:GORDON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2285 CROSS RD
Mailing Address - Street 2:
Mailing Address - City:GLENSIDE
Mailing Address - State:PA
Mailing Address - Zip Code:19038-5023
Mailing Address - Country:US
Mailing Address - Phone:215-887-5910
Mailing Address - Fax:215-887-0387
Practice Address - Street 1:2285 CROSS RD
Practice Address - Street 2:
Practice Address - City:GLENSIDE
Practice Address - State:PA
Practice Address - Zip Code:19038-5023
Practice Address - Country:US
Practice Address - Phone:215-887-5910
Practice Address - Fax:215-887-0387
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-02
Last Update Date:2008-03-18
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
PASC001507L213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015356250001Medicaid
PA7305038OtherAETNA
PA30002264OtherKEYSTONE MERCY
PA0060610000OtherKEYSTONE/AMERIHEALTH
PA30002264OtherKEYSTONE MERCY
PA7305038OtherAETNA