Healthcare Provider Details

I. General information

NPI: 1629496054
Provider Name (Legal Business Name): ANDREW JAMES GORDON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2014
Last Update Date: 12/10/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

781 AVENT FERRY RD STE 214
HOLLY SPRINGS NC
27540-7776
US

IV. Provider business mailing address

781 AVENT FERRY RD STE 214
HOLLY SPRINGS NC
27540-7776
US

V. Phone/Fax

Practice location:
  • Phone: 919-784-7874
  • Fax: 919-784-2708
Mailing address:
  • Phone: 919-784-7874
  • Fax: 919-784-2708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2024-02426
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number0101266662
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number291190
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: