Healthcare Provider Details

I. General information

NPI: 1962502955
Provider Name (Legal Business Name): LAURA SIDNEY GORDON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 SOUTHGATE STE 6
PENDLETON OR
97801-3974
US

IV. Provider business mailing address

1100 SOUTHGATE STE 6
PENDLETON OR
97801-3974
US

V. Phone/Fax

Practice location:
  • Phone: 564-276-6656
  • Fax: 541-276-1496
Mailing address:
  • Phone: 564-276-6656
  • Fax: 541-276-1496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberMD17630
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: