Provider Demographics
NPI:1205095452
Name:GORDON, HARRY WILLIAM (MD)
Entity type:Individual
Prefix:DR
First Name:HARRY
Middle Name:WILLIAM
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 1:12566 W BAJADA RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85383-2805
Mailing Address - Country:US
Mailing Address - Phone:480-948-4650
Mailing Address - Fax:623-388-3729
Practice Address - Street 1:12566 W BAJADA RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85383-2805
Practice Address - Country:US
Practice Address - Phone:480-948-4650
Practice Address - Fax:623-388-3729
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-03
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7672207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
BGFJNOtherMEDICARE
AZD36935Medicare UPIN