Healthcare Provider Details

I. General information

NPI: 1851482947
Provider Name (Legal Business Name): SHAWN R GORDEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 08/19/2024
Certification Date: 08/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56 MARIE LANGDON DR
MANCHESTER KY
40962-6329
US

IV. Provider business mailing address

509 MEMORIAL DR STE 2
MANCHESTER KY
40962-6196
US

V. Phone/Fax

Practice location:
  • Phone: 606-599-4080
  • Fax: 606-598-1688
Mailing address:
  • Phone: 606-598-5104
  • Fax: 606-598-0983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number39057
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberL3666
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number39057
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: