Healthcare Provider Details

I. General information

NPI: 1205465713
Provider Name (Legal Business Name): CLIFFORD WAYNE GORDON JR. DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2020
Last Update Date: 04/04/2024
Certification Date: 04/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 59TH ST W
BRADENTON FL
34209-4604
US

IV. Provider business mailing address

4460 IRONWOOD CIR APT 401
BRADENTON FL
34209-6894
US

V. Phone/Fax

Practice location:
  • Phone: 941-792-6611
  • Fax:
Mailing address:
  • Phone: 352-213-4514
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberUO9541
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: