Healthcare Provider Details

I. General information

NPI: 1669490348
Provider Name (Legal Business Name): GORDON K. AHLERS II MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 02/13/2020
Certification Date: 02/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 WASHINGTON HWY
MORRISVILLE VT
05661-8652
US

IV. Provider business mailing address

PO BOX 749
MORRISVILLE VT
05661-0749
US

V. Phone/Fax

Practice location:
  • Phone: 802-888-5639
  • Fax: 802-888-6040
Mailing address:
  • Phone: 802-888-5639
  • Fax: 802-888-6040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number48027511205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number48027511205
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG89199
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number042.0006927
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: