Healthcare Provider Details

I. General information

NPI: 1083686257
Provider Name (Legal Business Name): MARK ERNEST GORDON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 12/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 CLAY EDWARDS DR SUITE 400
NORTH KANSAS CITY MO
64116-3251
US

IV. Provider business mailing address

9411 N OAK TRFY SUITE LL1
KANSAS CITY MO
64155-2262
US

V. Phone/Fax

Practice location:
  • Phone: 816-421-4240
  • Fax: 816-421-5015
Mailing address:
  • Phone: 816-436-7072
  • Fax: 816-436-2743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberR1D12
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: