Provider Demographics
NPI:1821079013
Name:GORDON, CRAIG S (MD)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:S
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 1:21316 PROVINCIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77450-7580
Mailing Address - Country:US
Mailing Address - Phone:281-647-6667
Mailing Address - Fax:281-647-6610
Practice Address - Street 1:21316 PROVINCIAL BLVD
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77450-7580
Practice Address - Country:US
Practice Address - Phone:281-647-6667
Practice Address - Fax:281-647-6610
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF4848174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXB87898Medicare UPIN
TX87T171Medicare ID - Type Unspecified