Provider Demographics
NPI:1952399297
Name:GORDON, CARMELINA (MD)
Entity Type:Individual
Prefix:
First Name:CARMELINA
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 W NORTH ST STE 104
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-3196
Mailing Address - Country:US
Mailing Address - Phone:877-852-8463
Mailing Address - Fax:517-817-0144
Practice Address - Street 1:850 W NORTH ST STE 100
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-3196
Practice Address - Country:US
Practice Address - Phone:877-852-8463
Practice Address - Fax:517-841-3034
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301063145207W00000X, 207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4496389Medicaid
180044966OtherRAILROAD MEDICARE
MI180C846310OtherBCBSM
MI180H149970OtherBCBSM
MI4380786Medicaid
MIH18930Medicare UPIN
MI4380786Medicaid
MI0C84631024Medicare PIN