Healthcare Provider Details

I. General information

NPI: 1891875563
Provider Name (Legal Business Name): CHRISTOPHER BURNSIDE GORDON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 10/10/2023
Certification Date: 10/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS PLZ
DAYTON OH
45404-1815
US

IV. Provider business mailing address

PO BOX 933432
CLEVELAND OH
44193-0039
US

V. Phone/Fax

Practice location:
  • Phone: 937-641-4000
  • Fax: 937-641-4500
Mailing address:
  • Phone: 937-641-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number35.081599
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: