Healthcare Provider Details

I. General information

NPI: 1891892691
Provider Name (Legal Business Name): FREDRIC D GORDON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 03/17/2025
Certification Date: 03/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 WASHINGTON ST BLDG 40
BOSTON MA
02111-1552
US

IV. Provider business mailing address

168 CYNTHIA RD
NEWTON MA
02459-2864
US

V. Phone/Fax

Practice location:
  • Phone: 617-636-4886
  • Fax: 617-636-1003
Mailing address:
  • Phone: 617-291-3960
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number73902
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207RI0008X
TaxonomyHepatology Physician
License Number73902
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: