Provider Demographics
NPI:1811019268
Name:GORDON, CHARLES THOMAS III (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:THOMAS
Last Name:GORDON
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:11204 FARMLAND DR
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4522
Mailing Address - Country:US
Mailing Address - Phone:301-230-1808
Mailing Address - Fax:301-230-1808
Practice Address - Street 1:11204 FARMLAND DR
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-4522
Practice Address - Country:US
Practice Address - Phone:301-230-1808
Practice Address - Fax:301-230-1808
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00337162084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDF56895Medicare UPIN