Healthcare Provider Details

I. General information

NPI: 1487016200
Provider Name (Legal Business Name): GORDIAN NDUBIZU D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2016
Last Update Date: 11/18/2021
Certification Date: 11/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11116 MEDICAL CAMPUS RD
HAGERSTOWN MD
21742-6710
US

IV. Provider business mailing address

11116 MEDICAL CAMPUS RD
HAGERSTOWN MD
21742-6710
US

V. Phone/Fax

Practice location:
  • Phone: 301-790-8380
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberH92614
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: