Provider Demographics
NPI:1881965309
Name:FUQUA, GORDON ANDREW (MD)
Entity type:Individual
Prefix:DR
First Name:GORDON
Middle Name:ANDREW
Last Name:FUQUA
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 1:2131 N CLARK ST
Mailing Address - Street 2:# 9
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-6188
Mailing Address - Country:US
Mailing Address - Phone:312-623-8006
Mailing Address - Fax:
Practice Address - Street 1:2131 N CLARK ST
Practice Address - Street 2:# 9
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-6188
Practice Address - Country:US
Practice Address - Phone:312-623-8006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-13
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360419972084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry