Healthcare Provider Details

I. General information

NPI: 1316267339
Provider Name (Legal Business Name): DWAYNE KIRK GORDON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2010
Last Update Date: 07/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 N ORANGE AVE SUITE 235
ORLANDO FL
32804-4603
US

IV. Provider business mailing address

2501 N ORANGE AVE SUITE 235
ORLANDO FL
32804-4603
US

V. Phone/Fax

Practice location:
  • Phone: 407-303-7270
  • Fax: 407-303-7285
Mailing address:
  • Phone: 407-303-7270
  • Fax: 407-303-7285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME116883
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: