Healthcare Provider Details

I. General information

NPI: 1508426974
Provider Name (Legal Business Name): NATHAN ALLAN GORDON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2019
Last Update Date: 07/01/2022
Certification Date: 07/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 JAMES SIMPSON JR WAY
COVINGTON KY
41011-0801
US

IV. Provider business mailing address

PO BOX 635283
CINCINNATI OH
45263-5283
US

V. Phone/Fax

Practice location:
  • Phone: 859-655-4111
  • Fax: 859-655-4815
Mailing address:
  • Phone: 859-655-4111
  • Fax: 859-655-4815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number56731
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: