Provider Demographics
NPI:1851482947
Name:GORDEN, SHAWN R (MD)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:R
Last Name:GORDEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
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Mailing Address - Street 1:509 MEMORIAL DR STE 2
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40962-6196
Mailing Address - Country:US
Mailing Address - Phone:606-598-5104
Mailing Address - Fax:606-598-0983
Practice Address - Street 1:56 MARIE LANGDON DR
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40962-6329
Practice Address - Country:US
Practice Address - Phone:606-599-4080
Practice Address - Fax:606-598-1688
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXL3666207V00000X
KY39057207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2552545Medicaid
KY64091820Medicaid
11356327OtherCAQH ID
TX215019501Medicaid
TX215019501Medicaid