Provider Demographics
NPI:1831158955
Name:GORDON, PETER T (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:T
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 1:100 GANNETT DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-5900
Mailing Address - Country:US
Mailing Address - Phone:207-828-0361
Mailing Address - Fax:207-874-1483
Practice Address - Street 1:259 MAIN ST
Practice Address - Street 2:
Practice Address - City:YARMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04096-6723
Practice Address - Country:US
Practice Address - Phone:207-846-9013
Practice Address - Fax:207-523-8586
Is Sole Proprietor?:No
Enumeration Date:2006-03-18
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME012591207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
010557OtherANTHEM
ME311660099Medicaid
1040906OtherAETNA
B58102Medicare UPIN
MEMM203801Medicare PIN
010557OtherANTHEM