1407054901 NPI number — WILLIAM D. GORDON, O.D. INC.

Table of content: (NPI 1407054901)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407054901 NPI number — WILLIAM D. GORDON, O.D. INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILLIAM D. GORDON, O.D. INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
FAMILY EYE CARE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407054901
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/09/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3000 FORSYTHE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONROE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71201-3012
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-807-2020
Provider Business Mailing Address Fax Number:
318-388-1868

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3000 FORSYTHE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71201-3012
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-807-2020
Provider Business Practice Location Address Fax Number:
318-388-1868
Provider Enumeration Date:
07/05/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GORDON
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
DOCTOR OF OPTOMETRY
Authorized Official Telephone Number:
318-807-2020

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  LA909-230T , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1337170 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".