Provider Demographics
NPI:1255528584
Name:JONATHAN E GORDON OD PA
Entity type:Organization
Organization Name:JONATHAN E GORDON OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:P/D/C
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:321-454-4800
Mailing Address - Street 1:777 E MERRITT ISLAND CSWY
Mailing Address - Street 2:#221
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32952-3576
Mailing Address - Country:US
Mailing Address - Phone:321-454-4800
Mailing Address - Fax:321-454-2019
Practice Address - Street 1:777 E MERRITT ISLAND CSWY
Practice Address - Street 2:#221
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952-3576
Practice Address - Country:US
Practice Address - Phone:321-454-4800
Practice Address - Fax:321-454-2019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-01
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 3471152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty