Healthcare Provider Details

I. General information

NPI: 1154541803
Provider Name (Legal Business Name): MARILYN B GORDON, MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 03/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107A COUNTY RD
NORTH FALMOUTH MA
02556-2019
US

IV. Provider business mailing address

107A COUNTY RD
NORTH FALMOUTH MA
02556-2019
US

V. Phone/Fax

Practice location:
  • Phone: 508-564-5522
  • Fax: 508-564-5544
Mailing address:
  • Phone: 508-564-5522
  • Fax: 508-564-5544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number81230
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number81230
License Number StateMA

VIII. Authorized Official

Name: MARILYN B GORDON
Title or Position: OWNER
Credential: MD
Phone: 508-564-5522