Provider Demographics
NPI:1659330793
Name:GORDON, MICHAEL D (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:D
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 1:1218 W KILBOURN AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53233-1330
Mailing Address - Country:US
Mailing Address - Phone:414-276-6000
Mailing Address - Fax:414-276-1758
Practice Address - Street 1:1218 W KILBOURN AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233-1330
Practice Address - Country:US
Practice Address - Phone:414-276-6000
Practice Address - Fax:414-276-1758
Is Sole Proprietor?:No
Enumeration Date:2006-03-18
Last Update Date:2009-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI46004207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34436000Medicaid
WI34436000Medicaid
WI0758920001Medicare NSC
WI001402672Medicare ID - Type UnspecifiedMILWAUKEE COUNTY
WIH64651Medicare UPIN