Healthcare Provider Details

I. General information

NPI: 1497462485
Provider Name (Legal Business Name): JONATHAN GORDON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2022
Last Update Date: 09/17/2026
Certification Date: 10/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45211 HELM ST
PLYMOUTH MI
48170
US

IV. Provider business mailing address

45211 HELM ST
PLYMOUTH MI
48170
US

V. Phone/Fax

Practice location:
  • Phone: 480-777-0900
  • Fax: 480-777-1345
Mailing address:
  • Phone: 480-777-0900
  • Fax: 480-777-1345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: