Healthcare Provider Details

I. General information

NPI: 1457314288
Provider Name (Legal Business Name): O T GORDON JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2006
Last Update Date: 03/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1609 W 40TH AVE SUITE 312
PINE BLUFF AR
71603-6329
US

IV. Provider business mailing address

1609 W 40TH AVE SUITE 312
PINE BLUFF AR
71603-6329
US

V. Phone/Fax

Practice location:
  • Phone: 870-534-3344
  • Fax: 870-534-3517
Mailing address:
  • Phone: 870-534-3344
  • Fax: 870-534-3517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberC5353
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: