Provider Demographics
NPI:1184688145
Name:GORDON, DOUGLAS A (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:A
Last Name:GORDON
Suffix:
Gender:M
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:PO BOX 713130
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45271-0001
Mailing Address - Country:US
Mailing Address - Phone:937-415-9100
Mailing Address - Fax:937-415-9191
Practice Address - Street 1:7677 YANKEE ST
Practice Address - Street 2:SUITE 110
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-3475
Practice Address - Country:US
Practice Address - Phone:937-415-9100
Practice Address - Fax:937-415-9191
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-05-6322-G207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0725933Medicaid
OHP00356846OtherRAILROAD MEDICARE
OH0608343Medicare PIN
OHA17191Medicare UPIN
OH0608341Medicare PIN
OH0725933Medicaid