Provider Demographics
NPI:1205804267
Name:GORDON, GREGORY I (MD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:I
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 1:981045 NEBRASKA MEDICAL CTR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68198-1045
Mailing Address - Country:US
Mailing Address - Phone:402-559-1343
Mailing Address - Fax:402-559-1340
Practice Address - Street 1:981045 NEBRASKA MEDICAL CTR
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68198-1045
Practice Address - Country:US
Practice Address - Phone:402-559-1343
Practice Address - Fax:402-559-1340
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20010049742085R0202X
KS04-299132085R0202X
IL360929862085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE470785575Medicaid
NE098605120OtherMEDICARE ID - TYPE UNSPECIFIED
IL036092986Medicaid
ILH06752Medicare UPIN
IL036092986Medicaid