Provider Demographics
NPI:1134562762
Name:GORDAN, BRADLEY (DO)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:GORDAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3245 HEALTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1380
Mailing Address - Country:US
Mailing Address - Phone:574-647-2129
Mailing Address - Fax:
Practice Address - Street 1:500 ARCADE AVE STE 320
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-2477
Practice Address - Country:US
Practice Address - Phone:574-523-7900
Practice Address - Fax:574-523-7909
Is Sole Proprietor?:No
Enumeration Date:2013-04-13
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02006650A208600000X
IADO-05396208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1134562762Medicaid
IN300060816Medicaid
IN300060816Medicaid