Provider Demographics
NPI:1912001470
Name:GORDON, SAMUEL A S (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:A S
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 1:1095 MILITARY TRAIL, BOX # 7716
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33468-7716
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8177 GLADES ROAD, BAY 25
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33434
Practice Address - Country:US
Practice Address - Phone:561-472-9975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME60525207V00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0120051Medicaid
FL207V00000XOtherPLANNED PARENTHOOD OF SOUTH, EAST AND NORTH FLORIDA
FL1912001470OtherNPI
FL207V00000XOtherPLANNED PARENTHOOD OF SOUTH, EAST AND NORTH FLORIDA