Provider Demographics
NPI:1396776845
Name:GORDY, RICHARD G (OD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:G
Last Name:GORDY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:RICHARD
Other - Middle Name:G
Other - Last Name:GORDY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:5009 RIVERCHASE DRIVE
Mailing Address - Street 2:BUILDING 400 SUITE B
Mailing Address - City:PHENIX CITY
Mailing Address - State:AL
Mailing Address - Zip Code:36867
Mailing Address - Country:US
Mailing Address - Phone:334-291-5125
Mailing Address - Fax:
Practice Address - Street 1:5009 RIVER CHASE DR
Practice Address - Street 2:BLDG 100 SUITE C
Practice Address - City:PHENIX CITY
Practice Address - State:AL
Practice Address - Zip Code:36867-7425
Practice Address - Country:US
Practice Address - Phone:334-291-5125
Practice Address - Fax:334-291-9956
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALSA51TA630152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009931305Medicaid
AL51521264OtherBC