Provider Demographics
NPI:1336167816
Name:GORDON, JEFFERSON TAYLOR (MD)
Entity Type:Individual
Prefix:
First Name:JEFFERSON
Middle Name:TAYLOR
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 1:100 PROFESSIONAL PL
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3802
Mailing Address - Country:US
Mailing Address - Phone:770-832-6861
Mailing Address - Fax:770-832-9432
Practice Address - Street 1:100 PROFESSIONAL PL
Practice Address - Street 2:SUITE 202
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3802
Practice Address - Country:US
Practice Address - Phone:770-832-6861
Practice Address - Fax:770-832-9432
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033338207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000460996CMedicaid
GA000460996CMedicaid
F08950Medicare UPIN