Provider Demographics
NPI:1891923595
Name:GORDON, JESSE (DO)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 ANDERSON ST STE 101
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15212-5803
Mailing Address - Country:US
Mailing Address - Phone:412-322-4151
Mailing Address - Fax:844-389-1405
Practice Address - Street 1:127 ANDERSON ST STE 101
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15212-5803
Practice Address - Country:US
Practice Address - Phone:412-322-4151
Practice Address - Fax:844-389-1405
Is Sole Proprietor?:No
Enumeration Date:2009-07-01
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A12984207Q00000X
IL125056829390200000X
TXR3519207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102936677Medicaid