Provider Demographics
NPI:1962502955
Name:GORDON, LAURA SIDNEY (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:SIDNEY
Last Name:GORDON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 SOUTHGATE
Mailing Address - Street 2:STE 6
Mailing Address - City:PENDLETON
Mailing Address - State:OR
Mailing Address - Zip Code:97801-3974
Mailing Address - Country:US
Mailing Address - Phone:564-276-6656
Mailing Address - Fax:541-276-1496
Practice Address - Street 1:1100 SOUTHGATE
Practice Address - Street 2:STE 6
Practice Address - City:PENDLETON
Practice Address - State:OR
Practice Address - Zip Code:97801-3974
Practice Address - Country:US
Practice Address - Phone:564-276-6656
Practice Address - Fax:541-276-1496
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD17630208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR150155Medicaid
ORW1033-01OtherPACIFICSOURCE PROVIDER #
OR340020014OtherOR RAILROAD MEDICARE #
OR2408483-01OtherBC/BS OF OR PROVIDER #
OR150155Medicaid
OR340020014OtherOR RAILROAD MEDICARE #