Provider Demographics
NPI:1134776479
Name:GORDON, KEVIN BRUCE
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:BRUCE
Last Name:GORDON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1816 SYDENHAM TRL
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-8917
Mailing Address - Country:US
Mailing Address - Phone:757-635-0578
Mailing Address - Fax:
Practice Address - Street 1:1816 SYDENHAM TRAIL
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-8917
Practice Address - Country:US
Practice Address - Phone:757-635-0578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-21
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202009072183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist