Provider Demographics
NPI:1972557585
Name:GORDON, RICHARD ALLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:ALLEN
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 1:7600 S LEWIS AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-6836
Mailing Address - Country:US
Mailing Address - Phone:918-493-2229
Mailing Address - Fax:918-493-7819
Practice Address - Street 1:7600 S LEWIS AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-6836
Practice Address - Country:US
Practice Address - Phone:918-493-2229
Practice Address - Fax:918-493-7819
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11805208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100088660BMedicaid
245426701Medicare ID - Type Unspecified
OK100088660BMedicaid