Provider Demographics
NPI:1881629186
Name:GORDON, PAMELA R (MD)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:R
Last Name:GORDON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 MAHALANI ST
Mailing Address - Street 2:
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-2531
Mailing Address - Country:US
Mailing Address - Phone:808-243-6000
Mailing Address - Fax:
Practice Address - Street 1:80 MAHALANI ST
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-2531
Practice Address - Country:US
Practice Address - Phone:808-243-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD12233207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI00A0238707OtherHMSA BILLING NUMBER
HI52991901Medicaid
HIB47883Medicare UPIN
HI55100Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER