Provider Demographics
NPI:1942295027
Name:DONALDSON, GORDON R (DO)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:R
Last Name:DONALDSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4103 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ELVERSON
Mailing Address - State:PA
Mailing Address - Zip Code:19520-9378
Mailing Address - Country:US
Mailing Address - Phone:610-286-9064
Mailing Address - Fax:610-286-7832
Practice Address - Street 1:4103 MAIN ST
Practice Address - Street 2:
Practice Address - City:ELVERSON
Practice Address - State:PA
Practice Address - Zip Code:19520-9378
Practice Address - Country:US
Practice Address - Phone:610-286-9064
Practice Address - Fax:610-286-7832
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS006437L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E36822Medicare UPIN
588895Medicare ID - Type Unspecified