Healthcare Provider Details

I. General information

NPI: 1588663413
Provider Name (Legal Business Name): ROBERT GORDON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/21/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

965 S MAIN ST
PLYMOUTH MI
48170-2048
US

IV. Provider business mailing address

965 S MAIN ST
PLYMOUTH MI
48170-2048
US

V. Phone/Fax

Practice location:
  • Phone: 734-455-2970
  • Fax: 313-561-0277
Mailing address:
  • Phone: 734-455-2970
  • Fax: 313-561-0277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberRG008180
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: