Provider Demographics
NPI:1689684888
Name:GORDON, SAMUEL ANTONIO (PHD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:ANTONIO
Last Name:GORDON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 IRVING ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20010-2921
Mailing Address - Country:US
Mailing Address - Phone:202-877-1000
Mailing Address - Fax:202-291-5366
Practice Address - Street 1:102 IRVING ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20010-2921
Practice Address - Country:US
Practice Address - Phone:202-877-1000
Practice Address - Fax:202-291-5366
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPSY 1528103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
247626OtherMAMSI
5681292OtherAETNA NON HMO
DC 2528584OtherAETNA HMO
103645OtherKAISER
SMD 3839272OtherAETNA HMO
H360-0004OtherBS NCA
512762OtherNCPPO
H360-0004OtherBS NCA
DC 2528584OtherAETNA HMO