Healthcare Provider Details

I. General information

NPI: 1285630905
Provider Name (Legal Business Name): LEMUEL DURRELL GORDEN III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 03/14/2024
Certification Date: 03/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225B WINTON M BLOUNT LOOP
MONTGOMERY AL
36117-3507
US

IV. Provider business mailing address

225B WINTON M BLOUNT LOOP
MONTGOMERY AL
36117-3507
US

V. Phone/Fax

Practice location:
  • Phone: 334-263-6228
  • Fax: 334-265-9136
Mailing address:
  • Phone: 334-263-6228
  • Fax: 334-265-9136

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number22077
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: