Healthcare Provider Details

I. General information

NPI: 1821730425
Provider Name (Legal Business Name): KYLE SEBASTIAN GORDON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2022
Last Update Date: 04/13/2022
Certification Date: 03/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

FLORIDA ATLANTIC UNIVERSITY INTERNAL MEDICINE RESIDENCY 800 MEADOWS ROAD
BOCA RATON FL
33486
US

IV. Provider business mailing address

FLORIDA ATLANTIC UNIVERSITY INTERNAL MEDICINE RESIDENCY 800 MEADOWS ROAD
BOCA RATON FL
33486
US

V. Phone/Fax

Practice location:
  • Phone: 561-955-5365
  • Fax: 561-955-3577
Mailing address:
  • Phone: 561-955-5365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: