Healthcare Provider Details

I. General information

NPI: 1174525679
Provider Name (Legal Business Name): SHERRYL GAYE GORDON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 02/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 E JENNINGS AVE
EUSTIS FL
32726-6148
US

IV. Provider business mailing address

601 JENNINGS AVE
EUSTIS FL
32726-6148
US

V. Phone/Fax

Practice location:
  • Phone: 352-357-5311
  • Fax: 352-357-0659
Mailing address:
  • Phone: 352-357-5311
  • Fax: 352-357-0659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME90253
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: