Provider Demographics
NPI:1356401749
Name:GORDON, CECILIA BERNADETTE (DO)
Entity type:Individual
Prefix:
First Name:CECILIA
Middle Name:BERNADETTE
Last Name:GORDON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2620 NEW BERN AVE
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-1821
Mailing Address - Country:US
Mailing Address - Phone:919-833-3111
Mailing Address - Fax:919-832-3112
Practice Address - Street 1:212 S SALEM ST
Practice Address - Street 2:
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27502-1825
Practice Address - Country:US
Practice Address - Phone:919-362-5201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS9461207Q00000X
NC200301233207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOS9461OtherMEDICAL LICENSE
NC89135MOMedicaid
H99163Medicare UPIN