Healthcare Provider Details

I. General information

NPI: 1164591798
Provider Name (Legal Business Name): PHILLIP V GORDON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 09/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5149 N 9TH AVE
PENSACOLA FL
32504-8756
US

IV. Provider business mailing address

20 SEASHORE DR
PENSACOLA BEACH FL
32561-2427
US

V. Phone/Fax

Practice location:
  • Phone: 434-996-4974
  • Fax:
Mailing address:
  • Phone: 434-996-4974
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101227934
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberMD.201795
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number115952
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: