1992772644 NPI number — DR. CARRIE ANN GORDON M.D.

Table of content: DR. CARRIE ANN GORDON M.D. (NPI 1992772644)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992772644 NPI number — DR. CARRIE ANN GORDON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GORDON
Provider First Name:
CARRIE
Provider Middle Name:
ANN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1992772644
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/08/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5546
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DENVER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80217-5546
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-475-3500
Provider Business Mailing Address Fax Number:
801-475-3494

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 W LAYTON PARKWAY
Provider Second Line Business Practice Location Address:
SUITE 4C
Provider Business Practice Location Address City Name:
LAYTON
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84041
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-475-3240
Provider Business Practice Location Address Fax Number:
801-475-3241
Provider Enumeration Date:
03/01/2006

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: 207V00000X , with the licence number:  A88549 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 340625-1205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1992772644 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




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