Provider Demographics
NPI:1942316112
Name:GORDON, THAD BARRY (DC)
Entity Type:Individual
Prefix:DR
First Name:THAD
Middle Name:BARRY
Last Name:GORDON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1986 31ST AVENUE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-6627
Mailing Address - Country:US
Mailing Address - Phone:772-567-3334
Mailing Address - Fax:772-567-4523
Practice Address - Street 1:1986 31ST AVENUE
Practice Address - Street 2:SUITE 110
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-6627
Practice Address - Country:US
Practice Address - Phone:772-567-3334
Practice Address - Fax:772-567-4523
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH2470111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
4400124OtherUNITED HEALTHCARE
89915OtherBLUE CROSS BLUE SHIELD
4400124OtherUNITED HEALTHCARE
89915Medicare ID - Type Unspecified