Healthcare Provider Details

I. General information

NPI: 1023002300
Provider Name (Legal Business Name): GORDON CLINIC-ANTONIO GORDON MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2005
Last Update Date: 11/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

344 W 65TH ST SUITE 201-204
HIALEAH FL
33012-6719
US

IV. Provider business mailing address

344 W 65TH ST SUITE 201-204
HIALEAH FL
33012-6719
US

V. Phone/Fax

Practice location:
  • Phone: 305-556-6459
  • Fax: 305-556-9623
Mailing address:
  • Phone: 305-556-6459
  • Fax: 305-556-9623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0028982
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateFL

VIII. Authorized Official

Name: DR. ANTONIO M. GORDON JR.
Title or Position: PRESIDENT
Credential: MD
Phone: 305-556-6459