Healthcare Provider Details

I. General information

NPI: 1659455756
Provider Name (Legal Business Name): GARY M GORDON DPM PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 03/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2285 CROSS RD
GLENSIDE PA
19038
US

IV. Provider business mailing address

2285 CROSS RD
GLENSIDE PA
19038
US

V. Phone/Fax

Practice location:
  • Phone: 215-887-5910
  • Fax: 215-887-0387
Mailing address:
  • Phone: 215-887-5910
  • Fax: 215-887-0387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberSC00L57L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberSC001507L
License Number StatePA

VIII. Authorized Official

Name: GARY M GORDON
Title or Position: PRESIDENT
Credential: DPM
Phone: 215-887-5910