Provider Demographics
NPI:1912102682
Name:GORDON, ERIC
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:GORDON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1028 GROVE PARK CIR
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33436-9436
Mailing Address - Country:US
Mailing Address - Phone:561-789-5089
Mailing Address - Fax:561-965-8120
Practice Address - Street 1:1028 GROVE PARK CIR
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33436-9436
Practice Address - Country:US
Practice Address - Phone:561-789-5089
Practice Address - Fax:561-965-8120
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-20
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22161225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist