Healthcare Provider Details

I. General information

NPI: 1063854651
Provider Name (Legal Business Name): GORDON GUANXIONG MAO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: GUANXIONG MAO MD

II. Dates (important events)

Enumeration Date: 07/23/2013
Last Update Date: 02/17/2022
Certification Date: 02/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 W. 16TH STREET GOODMAN HALL SUITE 5100
INDIANAPOLIS IN
46202
US

IV. Provider business mailing address

250 N SHADELAND AVE
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-963-1300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number01085850B
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberMT2050
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number01085850A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: