Provider Demographics
NPI:1669749545
Name:GORDON, ROY G (OD)
Entity type:Individual
Prefix:DR
First Name:ROY
Middle Name:G
Last Name:GORDON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 LITTLE MOUNTAIN LN UNIT 101
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-8752
Mailing Address - Country:US
Mailing Address - Phone:360-416-6735
Mailing Address - Fax:
Practice Address - Street 1:2100 LITTLE MOUNTAIN LN
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-8752
Practice Address - Country:US
Practice Address - Phone:360-416-6735
Practice Address - Fax:360-424-6954
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-21
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60218053152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist