Healthcare Provider Details

I. General information

NPI: 1265914642
Provider Name (Legal Business Name): MELISSA GORDON ADULT NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2018
Last Update Date: 09/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1670 CLAIRMONT RD
DECATUR GA
30033-4004
US

IV. Provider business mailing address

1455 FOX FOREST CT SW
LILBURN GA
30047-5520
US

V. Phone/Fax

Practice location:
  • Phone: 404-321-6111
  • Fax:
Mailing address:
  • Phone: 770-381-0395
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberRN192865
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberRN192865
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: