Healthcare Provider Details

I. General information

NPI: 1922126093
Provider Name (Legal Business Name): MICHAEL BRIAN GORDON MD,PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 09/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 S ANDREWS AVE DEPARTMENT OF RADIOLOGY
FORT LAUDERDALE FL
33316-2510
US

IV. Provider business mailing address

1801 S PERIMETER RD STE 180
FORT LAUDERDALE FL
33309-7140
US

V. Phone/Fax

Practice location:
  • Phone: 954-355-5500
  • Fax:
Mailing address:
  • Phone: 954-839-8080
  • Fax: 954-839-8081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME100880
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: