Provider Demographics
NPI:1457344277
Name:BURTCH, GORDON D (MD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:D
Last Name:BURTCH
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 1:6821 PALISADES PARK CT
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-7131
Mailing Address - Country:US
Mailing Address - Phone:239-936-8555
Mailing Address - Fax:239-936-5611
Practice Address - Street 1:6821 PALISADES PARK CT
Practice Address - Street 2:SUITE 1
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-7131
Practice Address - Country:US
Practice Address - Phone:239-936-8555
Practice Address - Fax:239-936-5611
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0040302208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
2012355OtherAETNA HMO
FL062524800Medicaid
4110614OtherAETNA PPO
020032360OtherRAILROAD MEDICARE
FL15808OtherBLUE CROSS BLUE SHIELD
F61421Medicare UPIN
FL15808OtherBLUE CROSS BLUE SHIELD