Healthcare Provider Details

I. General information

NPI: 1558565085
Provider Name (Legal Business Name): PETER M GORDON MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2007
Last Update Date: 10/11/2023
Certification Date: 10/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 RIVERSIDE AVE FL 9
MINNEAPOLIS MN
55454-1450
US

IV. Provider business mailing address

2235 COMO AVE
SAINT PAUL MN
55108-1719
US

V. Phone/Fax

Practice location:
  • Phone: 612-365-8100
  • Fax:
Mailing address:
  • Phone: 617-512-3950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number221602
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: