Healthcare Provider Details

I. General information

NPI: 1558367490
Provider Name (Legal Business Name): RICHARD JOSEPH GORDON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 06/01/2022
Certification Date: 06/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W THOMAS RD STE 480
PHOENIX AZ
85013-4239
US

IV. Provider business mailing address

PO BOX 33269
PHOENIX AZ
85067-3269
US

V. Phone/Fax

Practice location:
  • Phone: 602-406-1150
  • Fax: 602-406-1159
Mailing address:
  • Phone: 602-406-4786
  • Fax: 916-636-4358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number18785
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number39181
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: