Provider Demographics
NPI:1457549156
Name:GORDON, ASSAF (MD)
Entity type:Individual
Prefix:
First Name:ASSAF
Middle Name:
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 1:11350 MCCORMICK RD
Mailing Address - Street 2:EXECUTIVE PLAZA 1, STE 501
Mailing Address - City:HUNT VALLEY
Mailing Address - State:MD
Mailing Address - Zip Code:21031-4637
Mailing Address - Country:US
Mailing Address - Phone:703-914-8000
Mailing Address - Fax:410-329-1054
Practice Address - Street 1:3803 FAIRFAX DR STE 400
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22203-5860
Practice Address - Country:US
Practice Address - Phone:703-738-4380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101242959208100000X, 2081P2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC127624YZNMedicare PIN
NY1416J1Medicare PIN