Healthcare Provider Details

I. General information

NPI: 1689644882
Provider Name (Legal Business Name): MICKEY E. GORDON DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 03/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9955 TAMIAMI TRL N SUITE 1
NAPLES FL
34108-1914
US

IV. Provider business mailing address

9955 TAMIAMI TRL N SUITE 1
NAPLES FL
34108-1914
US

V. Phone/Fax

Practice location:
  • Phone: 239-566-8800
  • Fax: 239-566-8778
Mailing address:
  • Phone: 239-566-8800
  • Fax: 239-566-8778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPO2638
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number0936
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number187
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: