Healthcare Provider Details

I. General information

NPI: 1033118658
Provider Name (Legal Business Name): EDWARD S. GORDON DPM PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25656 SCHOENHERR ROAD
WARREN MI
48089-1447
US

IV. Provider business mailing address

25656 SCHOENHERR ROAD
WARREN MI
48089-1447
US

V. Phone/Fax

Practice location:
  • Phone: 586-779-4820
  • Fax: 586-779-9535
Mailing address:
  • Phone: 586-779-4820
  • Fax: 586-779-9535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberEG0000597
License Number StateMI

VIII. Authorized Official

Name: DR. EDWARD SERGE GORDON
Title or Position: PRESIDENT
Credential: DPM
Phone: 586-779-4820