Healthcare Provider Details

I. General information

NPI: 1003234873
Provider Name (Legal Business Name): CHRISTOPHER GORDON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2014
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 N 500 W STE 200
PROVO UT
84601-1472
US

IV. Provider business mailing address

745 N 500 W STE 200
PROVO UT
84601-1472
US

V. Phone/Fax

Practice location:
  • Phone: 801-375-9292
  • Fax: 801-375-9290
Mailing address:
  • Phone: 801-375-9292
  • Fax: 801-375-9290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License Number11021602-1204
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number110216021204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: