Healthcare Provider Details

I. General information

NPI: 1346421203
Provider Name (Legal Business Name): JOEL P GORDON MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2007
Last Update Date: 01/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 S COUNTRY CLUB DR
LANTANA FL
33462-1204
US

IV. Provider business mailing address

424 S COUNTRY CLUB DR
LANTANA FL
33462-1204
US

V. Phone/Fax

Practice location:
  • Phone: 561-585-8183
  • Fax: 561-383-2997
Mailing address:
  • Phone: 561-585-8183
  • Fax: 561-383-2997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberME19252
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License NumberME19252
License Number StateFL

VIII. Authorized Official

Name: MRS. ITA CAMPOS
Title or Position: BILLING SUPERVISOR
Credential:
Phone: 561-585-8183