MEDICARE: CARMELINA GORDON M.D.

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
1	207W00000X	Ophthalmology Physician	4301063145	MI
2	207WX0107X	Retina Specialist (Ophthalmology) Physician	4301063145	MI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	180044966	OTHER		RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	180C846310	OTHER	MI	BCBSM
4	180H149970	OTHER	MI	BCBSM
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1952399297
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARMELINA GORDON M.D.

Provider Business Mailing Address
First Line	:	850 W NORTH ST STE 104
Second Line	:
City	:	JACKSON
State	:	MI
Zip	:	49202-3196
Country	:	US
Telephone Number	:	877-852-8463
Fax Number	:	517-817-0144

Provider Business Practice Location Address
First Line	:	850 W NORTH ST STE 100
Second Line	:
City	:	JACKSON
State	:	MI
Zip	:	49202-3196
Country	:	US
Telephone Number	:	877-852-8463
Fax Number	:	517-841-3034

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/11/2005
Last Update Date	:	07/21/2022

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Directions to “ CARMELINA GORDON M.D.” Practice Location

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