Provider Demographics
NPI:1801807912
Name:GORDON, MICHAEL A (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
Last Name:GORDON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3901 NW 79TH AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33166-6554
Mailing Address - Country:US
Mailing Address - Phone:305-431-2034
Mailing Address - Fax:305-717-1558
Practice Address - Street 1:3901 NW 79TH AVE STE 105
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33166-6554
Practice Address - Country:US
Practice Address - Phone:305-431-2034
Practice Address - Fax:305-717-9995
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2941152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6205305Medicaid
FLU69419Medicare UPIN