Provider Demographics
NPI:1871641803
Name:GORDON, ROBERT H (MS, PT, MED)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:H
Last Name:GORDON
Suffix:
Gender:M
Credentials:MS, PT, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1731 BEACON ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-5350
Mailing Address - Country:US
Mailing Address - Phone:617-739-4446
Mailing Address - Fax:
Practice Address - Street 1:4 HARTFORD ST
Practice Address - Street 2:204-A
Practice Address - City:NEWTON HIGHLANDS
Practice Address - State:MA
Practice Address - Zip Code:02461-1553
Practice Address - Country:US
Practice Address - Phone:617-823-8978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8262225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY69364Medicare ID - Type Unspecified