Provider Demographics
NPI:1356191449
Name:GORDON, DERRICK II
Entity type:Individual
Prefix:MR
First Name:DERRICK
Middle Name:
Last Name:GORDON
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 FLETCHER AVE NE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44705-4625
Mailing Address - Country:US
Mailing Address - Phone:330-268-6592
Mailing Address - Fax:
Practice Address - Street 1:2401 FLETCHER AVE NE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44705-4625
Practice Address - Country:US
Practice Address - Phone:330-268-6592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHTH9450693747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty