Healthcare Provider Details

I. General information

NPI: 1750384699
Provider Name (Legal Business Name): GORDON MARTIN GERSON JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 11/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 CASTLE CREEK RD
ASPEN CO
81611-1159
US

IV. Provider business mailing address

716 W BUTTERMILK RD 200 BUTTERMILK LANE
ASPEN CO
81611-2710
US

V. Phone/Fax

Practice location:
  • Phone: 970-544-7388
  • Fax: 970-544-1585
Mailing address:
  • Phone: 970-544-7388
  • Fax: 970-544-1585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number39095
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier64687341
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: