Provider Demographics
NPI:1710953468
Name:GOLDEN, GORDON R (MD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:R
Last Name:GOLDEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2405 RESEARCH PARKWAY
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-1624
Mailing Address - Country:US
Mailing Address - Phone:719-522-1133
Mailing Address - Fax:719-264-1772
Practice Address - Street 1:2405 RESEARCH PARKWAY
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-1624
Practice Address - Country:US
Practice Address - Phone:719-522-1133
Practice Address - Fax:719-264-1772
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0031428207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01314285Medicaid
CO01314285Medicaid
CO388547ZL1PMedicare PIN