Healthcare Provider Details

I. General information

NPI: 1306888334
Provider Name (Legal Business Name): CAROLE LYNN GORDON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 01/18/2021
Certification Date: 01/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12109 COUNTY ROAD 103 STE 2
OXFORD FL
34484-2951
US

IV. Provider business mailing address

12109 COUNTY ROAD 103
OXFORD FL
34484-2951
US

V. Phone/Fax

Practice location:
  • Phone: 352-259-4400
  • Fax: 352-787-0370
Mailing address:
  • Phone: 352-205-8981
  • Fax: 352-391-6498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberG2973
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License NumberG2973
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberME 110346
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: