Healthcare Provider Details

I. General information

NPI: 1013013937
Provider Name (Legal Business Name): ROBERT L. GORDON JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 12/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 W MORTON AVE SUITE 16A
JACKSONVILLE IL
62650-3145
US

IV. Provider business mailing address

1025 S 6TH ST
SPRINGFIELD IL
62703-2403
US

V. Phone/Fax

Practice location:
  • Phone: 217-479-9071
  • Fax:
Mailing address:
  • Phone: 217-528-7541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number036-107500
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: