Healthcare Provider Details

I. General information

NPI: 1407849722
Provider Name (Legal Business Name): STEPHANIE H GORDON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 08/06/2012
Certification Date:
Deactivation Date: 03/27/2006
Reactivation Date: 04/07/2006

III. Provider practice location address

2750 OWENS RD SW SUITE A
CONYERS GA
30094-3991
US

IV. Provider business mailing address

2750 OWENS RD SW SUITE A
CONYERS GA
30094-3991
US

V. Phone/Fax

Practice location:
  • Phone: 678-413-4644
  • Fax: 678-413-4624
Mailing address:
  • Phone: 678-413-4644
  • Fax: 678-413-4624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number049382
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: