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NPI Code Detail

MEDICARE: MR. DAVID ALAN GORDON AT

MEDICARE: MR. DAVID ALAN GORDON AT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12255A2300XAthletic Trainer00140MO

General Provider Information

NPI Number : 1558334771
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. DAVID ALAN GORDON AT
Provider Business Mailing Address
First Line : 3407 S HALL AVE
Second Line :
City : SPRINGFIELD
State : MO
Zip : 65804-4800
Country : US
Telephone Number : 417-890-1354
Fax Number :
Provider Business Practice Location Address
First Line : 1500 N OAKLAND AVE
Second Line :
City : BOLIVAR
State : MO
Zip : 65613-3011
Country : US
Telephone Number : 417-777-7763
Fax Number : 417-777-4378
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/08/2006
Last Update Date : 07/08/2007

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