Provider Demographics
NPI:1740767102
Name:STEPHEN W GORDON MD, PLLC
Entity type:Organization
Organization Name:STEPHEN W GORDON MD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:WINSLOW
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-242-6900
Mailing Address - Street 1:9101 W SAHARA AVE # 105-54
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-5772
Mailing Address - Country:US
Mailing Address - Phone:702-242-6900
Mailing Address - Fax:702-242-5107
Practice Address - Street 1:9101 W SAHARA AVE # 105-54
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-5772
Practice Address - Country:US
Practice Address - Phone:702-242-6900
Practice Address - Fax:702-242-5107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-27
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV79862086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVE0351002018-8OtherENTITY #