Healthcare Provider Details

I. General information

NPI: 1396747036
Provider Name (Legal Business Name): GORDON N SHECKET MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 08/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 GREENGLADE AVE
WORTHINGTON OH
43085-2291
US

IV. Provider business mailing address

501 GREENGLADE AVE CORPATH-CRED
WORTHINGTON OH
43085-2291
US

V. Phone/Fax

Practice location:
  • Phone: 614-436-6436
  • Fax:
Mailing address:
  • Phone: 614-436-6436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZN0500X
TaxonomyNeuropathology Physician
License Number35040207
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number35040207
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: