Healthcare Provider Details

I. General information

NPI: 1184597544
Provider Name (Legal Business Name): TRAVIS DANIEL GORDON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2025
Last Update Date: 09/24/2025
Certification Date: 09/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4353 CLAYTON AVE
SAINT LOUIS MO
63110-1621
US

IV. Provider business mailing address

4591 MCREE AVE # 417
SAINT LOUIS MO
63110-2237
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-0700
  • Fax:
Mailing address:
  • Phone: 604-968-6748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License Number2025027678
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: