Healthcare Provider Details

I. General information

NPI: 1679598627
Provider Name (Legal Business Name): ALENA GORDON D.P.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 05/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6330 PRIMROSE HILL CT
NORCROSS GA
30092-4544
US

IV. Provider business mailing address

PO BOX 769609
ROSWELL GA
30076-8224
US

V. Phone/Fax

Practice location:
  • Phone: 404-365-0160
  • Fax: 770-903-0169
Mailing address:
  • Phone: 404-365-0160
  • Fax: 770-903-0169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPOD001086
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberPOD001086
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberPOD001086
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: