Provider Demographics
NPI:1265433429
Name:GORDON, MICHAEL B (OD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:B
Last Name:GORDON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PETERBOROUGH
Mailing Address - State:NH
Mailing Address - Zip Code:03458-2417
Mailing Address - Country:US
Mailing Address - Phone:603-924-1611
Mailing Address - Fax:603-924-1609
Practice Address - Street 1:9 MAIN ST
Practice Address - Street 2:
Practice Address - City:PETERBOROUGH
Practice Address - State:NH
Practice Address - Zip Code:03458-2417
Practice Address - Country:US
Practice Address - Phone:603-924-1611
Practice Address - Fax:603-924-1609
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH530152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U18535Medicare UPIN