Healthcare Provider Details

I. General information

NPI: 1649287251
Provider Name (Legal Business Name): JEFFREY GORDON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 WALNUT ST. JEFFERSON UNIVERSITY HOSPITAL
PHILADELPHIA PA
19107
US

IV. Provider business mailing address

700 US RT 130 N SUITE 203
CINNAMINSON NJ
08077
US

V. Phone/Fax

Practice location:
  • Phone: 215-503-1340
  • Fax: 215-503-1342
Mailing address:
  • Phone: 856-829-9345
  • Fax: 856-829-0580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD059192L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: