1215992029 NPI number — DR. ELY R GORDON DO, MPH

Table of content: DR. ELY R GORDON DO, MPH (NPI 1215992029)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215992029 NPI number — DR. ELY R GORDON DO, MPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GORDON
Provider First Name:
ELY
Provider Middle Name:
R
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO, MPH
Provider Gender Code:
M

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:
1215992029
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5012 S US HWY 75, SUITE 300
Provider Second Line Business Mailing Address:
ATTN BILLING
Provider Business Mailing Address City Name:
DENISON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75020-4589
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-795-5506
Provider Business Mailing Address Fax Number:
580-795-5145

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 BROOKSIDE DRIVE
Provider Second Line Business Practice Location Address:
PO BOX 847
Provider Business Practice Location Address City Name:
MADILL
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73446-0847
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-795-5506
Provider Business Practice Location Address Fax Number:
580-795-5145
Provider Enumeration Date:
04/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  DO 621 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: DO 621 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 2006023036 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 2006023036 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0411221 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 110187817 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000008373 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 51008373 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".




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