Healthcare Provider Details

I. General information

NPI: 1689675449
Provider Name (Legal Business Name): GARY M GORDON DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 03/18/2008
Certification Date:
Deactivation Date: 03/21/2006
Reactivation Date: 03/28/2006

III. Provider practice location address

2285 CROSS RD
GLENSIDE PA
19038-5023
US

IV. Provider business mailing address

2285 CROSS RD
GLENSIDE PA
19038-5023
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 NumberSC001507L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: