1790075851 NPI number — DR. ZACHARY NATHAN GORDON MD

Table of content: DR. ZACHARY NATHAN GORDON MD (NPI 1790075851)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790075851 NPI number — DR. ZACHARY NATHAN GORDON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GORDON
Provider First Name:
ZACHARY
Provider Middle Name:
NATHAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GORDON
Provider Other First Name:
ZACH
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1790075851
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/11/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2605 N LEBANON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEBANON
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46052-1476
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2705 N LEBANON ST STE 265
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEBANON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46052
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-485-8730
Provider Business Practice Location Address Fax Number:
765-485-8739
Provider Enumeration Date:
04/11/2011

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: 2083C0008X , with the licence number:  01077056A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208800000X , with the licence number: 01077056A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 201369920 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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