Provider Demographics
NPI:1356303747
Name:GORDON, RONALD D (MD)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:D
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 1:3811 EAST BELL ROAD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032
Mailing Address - Country:US
Mailing Address - Phone:602-482-7676
Mailing Address - Fax:602-482-6152
Practice Address - Street 1:3811 EAST BELL ROAD
Practice Address - Street 2:SUITE 208
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032
Practice Address - Country:US
Practice Address - Phone:602-482-7676
Practice Address - Fax:602-482-6152
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-03
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ85032086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ70412OtherPTAN
AZ1356303747Medicare PIN
AZD36936Medicare UPIN