Healthcare Provider Details

I. General information

NPI: 1073541819
Provider Name (Legal Business Name): MICHAEL LAWRENCE GORDON DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 12/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17215 RED OAK DR SUITE 102
HOUSTON TX
77090-2697
US

IV. Provider business mailing address

17215 RED OAK DR SUITE 102
HOUSTON TX
77090-2697
US

V. Phone/Fax

Practice location:
  • Phone: 281-444-4114
  • Fax: 281-444-7789
Mailing address:
  • Phone: 281-444-4114
  • Fax: 281-444-7789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberTX1487
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number1487
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: