Provider Demographics
NPI:1972689750
Name:GORDON, MARTYN D (MD)
Entity Type:Individual
Prefix:
First Name:MARTYN
Middle Name:D
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 1:1604 LANCASTER DR
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051
Mailing Address - Country:US
Mailing Address - Phone:817-481-8661
Mailing Address - Fax:817-416-8801
Practice Address - Street 1:1604 LANCASTER DR
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051
Practice Address - Country:US
Practice Address - Phone:817-481-8661
Practice Address - Fax:817-416-8801
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG5101207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0354078Medicaid
TX00QA69Medicare ID - Type Unspecified
TX0354078Medicaid