Provider Demographics
NPI:1457410110
Name:GORDON, DAVID M (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:M
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 1:4900 153RD PL SW
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-4435
Mailing Address - Country:US
Mailing Address - Phone:425-583-4819
Mailing Address - Fax:425-595-3905
Practice Address - Street 1:930 N BROADWAY
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-1409
Practice Address - Country:US
Practice Address - Phone:425-317-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG42527207Q00000X
WAMD60644369207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2067764Medicaid