Provider Demographics
NPI:1023115920
Name:GORDON, TERESA K III
Entity type:Individual
Prefix:MS
First Name:TERESA
Middle Name:K
Last Name:GORDON
Suffix:III
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:TERESA
Other - Middle Name:K
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3625 S LAKE PARK AVE
Mailing Address - Street 2:#1107
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60653-1468
Mailing Address - Country:US
Mailing Address - Phone:773-538-1637
Mailing Address - Fax:
Practice Address - Street 1:3625 S LAKE PARK AVE
Practice Address - Street 2:#1107
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60653-1468
Practice Address - Country:US
Practice Address - Phone:773-538-1637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL172A00000X172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver