Provider Demographics
NPI:1669562500
Name:JEREMY M GORDON DC PA
Entity type:Organization
Organization Name:JEREMY M GORDON DC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:M
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:386-734-9995
Mailing Address - Street 1:905 N STONE ST
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-2521
Mailing Address - Country:US
Mailing Address - Phone:386-734-9995
Mailing Address - Fax:386-734-9949
Practice Address - Street 1:905 N STONE ST
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-2521
Practice Address - Country:US
Practice Address - Phone:386-734-9995
Practice Address - Fax:386-734-9949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH7770261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL55875OtherBLUE CROSS BLUE SHIELD
FL55875ZMedicare ID - Type Unspecified