Provider Demographics
NPI:1790865806
Name:GORDON, KENNETH B (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:B
Last Name:GORDON
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 1:10000 W BLUEMOUND RD
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4321
Mailing Address - Country:US
Mailing Address - Phone:414-454-8000
Mailing Address - Fax:414-805-3888
Practice Address - Street 1:10000 W BLUEMOUND RD
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-4321
Practice Address - Country:US
Practice Address - Phone:414-454-8000
Practice Address - Fax:414-805-3888
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036086146207N00000X
WI66663207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1790865806Medicaid
WI1790865806Medicaid