Provider Demographics
NPI:1982652939
Name:GORDON, MARK R (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:R
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:PO BOX 5009
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5009
Mailing Address - Country:US
Mailing Address - Phone:605-977-5000
Mailing Address - Fax:605-977-5377
Practice Address - Street 1:4520 W 69TH ST
Practice Address - Street 2:NORTH CENTRAL HEART INSTITUTE
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108
Practice Address - Country:US
Practice Address - Phone:605-977-5000
Practice Address - Fax:605-977-5377
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD3929207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN331503700Medicaid
10492OtherHEALTHPARTNERS
MN165025OtherUCARE
25-00667OtherMEDICA SELECTCARE
IA33333OtherIA BCBS #
SD6002892Medicaid
931451030123OtherPREFERRED ONE
IA0549402Medicaid
MN101T6GOOtherMN BCBS - PLAN 91057NO
MN346L9GOOtherMN BCBS - PLAN 538R2NO
SD3929OtherDAKOTACARE
SD0008426OtherSD BCBS
MN060003507Medicare PIN
SD3929OtherDAKOTACARE
SD0008426OtherSD BCBS
MN331503700Medicaid
IA0549402Medicaid