Provider Demographics
NPI:1205927464
Name:POINTER, GORDON M (DO)
Entity type:Individual
Prefix:MR
First Name:GORDON
Middle Name:M
Last Name:POINTER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:627 EAST 2ND ST
Mailing Address - Street 2:
Mailing Address - City:KEWANEE
Mailing Address - State:IL
Mailing Address - Zip Code:61443
Mailing Address - Country:US
Mailing Address - Phone:309-852-6514
Mailing Address - Fax:309-856-5705
Practice Address - Street 1:627 EAST 2ND ST
Practice Address - Street 2:
Practice Address - City:KEWANEE
Practice Address - State:IL
Practice Address - Zip Code:61443
Practice Address - Country:US
Practice Address - Phone:309-852-6514
Practice Address - Fax:309-856-5705
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038007262111N00000X
IAA5729111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038007262Medicaid
0008184020Medicare UPIN
IL038007262Medicaid