Healthcare Provider Details

I. General information

NPI: 1740767102
Provider Name (Legal Business Name): STEPHEN W GORDON MD, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2018
Last Update Date: 07/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9101 W SAHARA AVE # 105-54
LAS VEGAS NV
89117-5772
US

IV. Provider business mailing address

9101 W SAHARA AVE # 105-54
LAS VEGAS NV
89117-5772
US

V. Phone/Fax

Practice location:
  • Phone: 702-242-6900
  • Fax: 702-242-5107
Mailing address:
  • Phone: 702-242-6900
  • Fax: 702-242-5107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number7986
License Number StateNV

VIII. Authorized Official

Name: DR. STEPHEN WINSLOW GORDON
Title or Position: MANAGING MEMBER
Credential: MD
Phone: 702-242-6900