Provider Demographics
NPI:1912972647
Name:BASKIN, GORDON ST CLAIR (MD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:ST CLAIR
Last Name:BASKIN
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 1:1050 SE MONTEREY RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-4512
Mailing Address - Country:US
Mailing Address - Phone:772-781-5960
Mailing Address - Fax:772-419-0190
Practice Address - Street 1:1050 SE MONTEREY RD
Practice Address - Street 2:SUITE 204
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-4512
Practice Address - Country:US
Practice Address - Phone:772-781-5960
Practice Address - Fax:772-419-0190
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME045009207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL264953500Medicaid
FL264953500Medicaid
FL79925ZMedicare ID - Type Unspecified