Provider Demographics
NPI:1265963367
Name:GORDON, RYAN DOUGLAS (MD)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:DOUGLAS
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:VCUHS GME ADMINISTRATION, BOX 980257
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23298-0257
Mailing Address - Country:US
Mailing Address - Phone:804-828-9783
Mailing Address - Fax:
Practice Address - Street 1:417 N 11TH ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-5024
Practice Address - Country:US
Practice Address - Phone:804-828-9849
Practice Address - Fax:804-828-2744
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-21
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012787822086S0129X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery