Healthcare Provider Details

I. General information

NPI: 1356303747
Provider Name (Legal Business Name): RONALD D GORDON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2006
Last Update Date: 01/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3811 EAST BELL ROAD SUITE 208
PHOENIX AZ
85032
US

IV. Provider business mailing address

3811 EAST BELL ROAD SUITE 208
PHOENIX AZ
85032
US

V. Phone/Fax

Practice location:
  • Phone: 602-482-7676
  • Fax: 602-482-6152
Mailing address:
  • Phone: 602-482-7676
  • Fax: 602-482-6152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number8503
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: