Healthcare Provider Details

I. General information

NPI: 1982686523
Provider Name (Legal Business Name): NICOLE MICHELLE GORDON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2005
Last Update Date: 10/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 PEACHTREE ST NE STE 1600
ATLANTA GA
30308-2246
US

IV. Provider business mailing address

1001 SUMMIT BLVD STE 200
BROOKHAVEN GA
30319-6410
US

V. Phone/Fax

Practice location:
  • Phone: 404-881-1094
  • Fax: 404-874-1249
Mailing address:
  • Phone: 770-989-1668
  • Fax: 678-388-1749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number53536
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: