Healthcare Provider Details

I. General information

NPI: 1497183404
Provider Name (Legal Business Name): MR. MARK GORDON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2013
Last Update Date: 12/20/2025
Certification Date: 12/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 N UNIVERSITY DR STE A106
LAUDERHILL FL
33351-6243
US

IV. Provider business mailing address

4300 N UNIVERSITY DR STE A106
LAUDERHILL FL
33351-6243
US

V. Phone/Fax

Practice location:
  • Phone: 786-273-0728
  • Fax: 954-639-7433
Mailing address:
  • Phone: 786-273-0728
  • Fax: 954-639-7433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LC1500X
TaxonomyCommunity Health Nurse Practitioner
License Number11017993
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11017993
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11017993
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: