Provider Demographics
NPI:1982686523
Name:GORDON, NICOLE MICHELLE (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MICHELLE
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 1:1001 SUMMIT BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30319-6410
Mailing Address - Country:US
Mailing Address - Phone:770-989-1668
Mailing Address - Fax:678-388-1749
Practice Address - Street 1:550 PEACHTREE ST NE STE 1600
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-2246
Practice Address - Country:US
Practice Address - Phone:404-881-1094
Practice Address - Fax:404-874-1249
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA53536207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA647773539AMedicaid
GA10BDHJPMedicare ID - Type Unspecified
GA647773539AMedicaid