Provider Demographics
NPI:1396747036
Name:SHECKET, GORDON N (MD)
Entity type:Individual
Prefix:
First Name:GORDON
Middle Name:N
Last Name:SHECKET
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 1:501 GREENGLADE AVE
Mailing Address - Street 2:CORPATH-CRED
Mailing Address - City:WORTHINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43085-2291
Mailing Address - Country:US
Mailing Address - Phone:614-436-6436
Mailing Address - Fax:
Practice Address - Street 1:501 GREENGLADE AVE
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:OH
Practice Address - Zip Code:43085-2291
Practice Address - Country:US
Practice Address - Phone:614-436-6436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35040207207ZN0500X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZN0500XAllopathic & Osteopathic PhysiciansPathologyNeuropathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0626960Medicaid
OH220023091OtherRR MEDICARE
OH0626960Medicaid