Provider Demographics
NPI:1255636817
Name:M.D. GORDON O.D., LLC
Entity type:Organization
Organization Name:M.D. GORDON O.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:316-788-2020
Mailing Address - Street 1:1221 N ROCK RD
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:KS
Mailing Address - Zip Code:67037-3678
Mailing Address - Country:US
Mailing Address - Phone:316-788-2020
Mailing Address - Fax:316-788-7451
Practice Address - Street 1:1221 N ROCK RD
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:KS
Practice Address - Zip Code:67037-3678
Practice Address - Country:US
Practice Address - Phone:316-788-2020
Practice Address - Fax:316-788-7451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-12
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1046-3152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty