Provider Demographics
NPI:1952454290
Name:GORDON, JOSHIAH R (DO)
Entity Type:Individual
Prefix:
First Name:JOSHIAH
Middle Name:R
Last Name:GORDON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 N GRAND AVE
Mailing Address - Street 2:SUITE 140
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-2700
Mailing Address - Country:US
Mailing Address - Phone:719-564-1542
Mailing Address - Fax:719-566-0916
Practice Address - Street 1:1600 N GRAND AVE
Practice Address - Street 2:SUITE 140
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2700
Practice Address - Country:US
Practice Address - Phone:719-564-1542
Practice Address - Fax:719-566-0916
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO49719207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1952454290OtherNPI
CO37708830Medicaid