Healthcare Provider Details

I. General information

NPI: 1215992029
Provider Name (Legal Business Name): ELY R GORDON DO, MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 BROOKSIDE DRIVE PO BOX 847
MADILL OK
73446-0847
US

IV. Provider business mailing address

5012 S US HWY 75, SUITE 300 ATTN BILLING
DENISON TX
75020-4589
US

V. Phone/Fax

Practice location:
  • Phone: 580-795-5506
  • Fax: 580-795-5145
Mailing address:
  • Phone: 580-795-5506
  • Fax: 580-795-5145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberDO 621
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberDO 621
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2006023036
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2006023036
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: