1740767102 NPI number — STEPHEN W GORDON MD, PLLC

Table of content: (NPI 1740767102)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740767102 NPI number — STEPHEN W GORDON MD, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STEPHEN W GORDON MD, PLLC
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:
Provider Other Organization Name Type Code:
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:
1740767102
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/27/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9101 W SAHARA AVE # 105-54
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89117-5772
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-242-6900
Provider Business Mailing Address Fax Number:
702-242-5107

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9101 W SAHARA AVE # 105-54
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89117-5772
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-242-6900
Provider Business Practice Location Address Fax Number:
702-242-5107
Provider Enumeration Date:
07/27/2018

Additional Information

Authorized Official

Authorized Official Last Name:
GORDON
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
WINSLOW
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
702-242-6900

Provider Taxonomy Codes

  • Taxonomy code: 2086S0122X , with the licence number:  7986 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: E0351002018-8 . This is a "ENTITY #" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".




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