Provider Demographics
NPI:1891727830
Name:GORDON, EDWARD I (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:I
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 1:202 AGEE ST
Mailing Address - Street 2:
Mailing Address - City:FARMVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23901-2617
Mailing Address - Country:US
Mailing Address - Phone:434-392-6143
Mailing Address - Fax:434-392-3866
Practice Address - Street 1:2003 COBB ST
Practice Address - Street 2:
Practice Address - City:FARMVILLE
Practice Address - State:VA
Practice Address - Zip Code:23901-2603
Practice Address - Country:US
Practice Address - Phone:434-392-6106
Practice Address - Fax:434-392-3866
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101023260207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101023260OtherLICENSE
VA56-13027Medicaid
012915085Medicare ID - Type Unspecified
VAB09562Medicare UPIN