Provider Demographics
NPI:1982609665
Name:GORDON, LAWRENCE W (MD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:W
Last Name:GORDON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1000 DEPT 448
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148-0448
Mailing Address - Country:US
Mailing Address - Phone:901-682-1100
Mailing Address - Fax:901-682-6915
Practice Address - Street 1:6005 PARK AVE
Practice Address - Street 2:STE 624B
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-5221
Practice Address - Country:US
Practice Address - Phone:901-682-1100
Practice Address - Fax:901-682-6915
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN19749207W00000X, 207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR146871001Medicaid
AR5L961OtherARKANSAS MEDICARE
MS0119321Medicaid
AR5L961OtherBLUE CROSS OF ARKANSAS
TN3050718Medicaid
TN180031674OtherRAILROAD MEDICARE
TN3066300OtherBLUE CROSS OF TENNESSEE
ARP00777025OtherRAILROAD MEDICARE
TN3050717Medicare PIN
ARP00777025OtherRAILROAD MEDICARE