Provider Demographics
NPI:1891892691
Name:GORDON, FREDRIC D (MD)
Entity Type:Individual
Prefix:
First Name:FREDRIC
Middle Name:D
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 1:41 MALL RD
Mailing Address - Street 2:4 WEST
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01805-0001
Mailing Address - Country:US
Mailing Address - Phone:781-744-5100
Mailing Address - Fax:781-744-5743
Practice Address - Street 1:41 MALL RD
Practice Address - Street 2:4 WEST
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01805-0001
Practice Address - Country:US
Practice Address - Phone:781-744-8000
Practice Address - Fax:781-744-5743
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA73902207RI0008X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0008XAllopathic & Osteopathic PhysiciansInternal MedicineHepatology
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110055325AMedicaid
MA3133745Medicaid
MA110055325AMedicaid
MA3133745Medicaid