Provider Demographics
NPI:1932191582
Name:GORDON, ALAN N (MD)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:N
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 1:840 PINE ST
Mailing Address - Street 2:STE 760
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-2100
Mailing Address - Country:US
Mailing Address - Phone:478-633-6090
Mailing Address - Fax:478-633-4080
Practice Address - Street 1:840 PINE ST
Practice Address - Street 2:STE 760
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2100
Practice Address - Country:US
Practice Address - Phone:478-633-6090
Practice Address - Fax:478-633-4080
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2013-05-23
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-04-10
Provider Licenses
StateLicense IDTaxonomies
GA066740207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL278322300Medicaid
AZ778269Medicaid
AZB87894Medicare UPIN
FL278322300Medicaid