Provider Demographics
NPI:1851355218
Name:GORDON, OTIS T (MD)
Entity Type:Individual
Prefix:
First Name:OTIS
Middle Name:T
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 1:417 N UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-3108
Mailing Address - Country:US
Mailing Address - Phone:501-666-0249
Mailing Address - Fax:501-666-4340
Practice Address - Street 1:417 N UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-3108
Practice Address - Country:US
Practice Address - Phone:501-666-0249
Practice Address - Fax:501-666-4340
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE4082207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARP00348668OtherRAIL ROAD MEDICARE
AR03120019200OtherQUALCHOICE
AR156781001Medicaid
AR5N145OtherBLUE CROSS BLUE SHIELD
AR7867673OtherAETNA
AR156781001Medicaid
AR5N145C989Medicare PIN