Healthcare Provider Details

I. General information

NPI: 1871105429
Provider Name (Legal Business Name): ROBERT HENRY GORDON SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2020
Last Update Date: 08/17/2020
Certification Date: 08/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1119 SAND CREEK LOOP
OCOEE FL
34761-1434
US

IV. Provider business mailing address

PO BOX 617045
ORLANDO FL
32861-7045
US

V. Phone/Fax

Practice location:
  • Phone: 407-346-9498
  • Fax:
Mailing address:
  • Phone: 407-346-9498
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number236888
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: