Provider Demographics
NPI:1184379828
Name:GORDON, SAMANTHA KELLY (DO)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:KELLY
Last Name:GORDON
Suffix:
Gender:
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:NAVAL HOSPITAL GUANTANAMO BAY
Mailing Address - Street 2:PSC 1005 BOX 110185
Mailing Address - City:FPO
Mailing Address - State:AL
Mailing Address - Zip Code:34009
Mailing Address - Country:US
Mailing Address - Phone:757-458-2998
Mailing Address - Fax:
Practice Address - Street 1:NAVAL HOSPITAL GUANTANAMO BAY
Practice Address - Street 2:PSC 1005 BOX 110185
Practice Address - City:FPO
Practice Address - State:AL
Practice Address - Zip Code:34009
Practice Address - Country:US
Practice Address - Phone:757-458-2998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-21
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171000000X
VA0102208040208000000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice