Provider Demographics
NPI:1821094301
Name:GOURDIN, THEODORE G (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:G
Last Name:GOURDIN
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 1:2001 2ND AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29486-7887
Mailing Address - Country:US
Mailing Address - Phone:843-793-5182
Mailing Address - Fax:843-266-5125
Practice Address - Street 1:1962 CHARLIE HALL BLVD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5837
Practice Address - Country:US
Practice Address - Phone:843-722-8000
Practice Address - Fax:843-647-6066
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13033174400000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC130334Medicaid
SCE51366Medicare UPIN