Provider Demographics
NPI:1275748501
Name:KRISTA GORDON MD PC
Entity Type:Organization
Organization Name:KRISTA GORDON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:GELVIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-536-7546
Mailing Address - Street 1:5366 NW CACHE RD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-3335
Mailing Address - Country:US
Mailing Address - Phone:580-536-7546
Mailing Address - Fax:580-581-2051
Practice Address - Street 1:5366 NW CACHE RD
Practice Address - Street 2:SUITE 6
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-3353
Practice Address - Country:US
Practice Address - Phone:580-536-7546
Practice Address - Fax:580-581-2051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK21237207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK900522624OtherMEDICARE PTAN