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General NPI Number Information
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NPI Number | 1255636817
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Entity Type | Organization
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Legal Business Name | M.D. GORDON O.D., LLC
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Dates
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Enumeration Date | 01/12/2011
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Last Update Date | 10/19/2016
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Provider Practice Location Address
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Address Line | 1221 N ROCK RD
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City | DERBY
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State | KS
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Zip | 67037-3678
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Country | US
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Telephone | 316-788-2020
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Fax | 316-788-7451
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Provider Business Mailing Address
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Address Line | 1221 N ROCK RD
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City | DERBY
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State | KS
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Zip | 67037-3678
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Country | US
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Telephone | 316-788-2020
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Fax | 316-788-7451
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Authorized Official
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Title or Position | PRESIDENT
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Name | MICHAEL D GORDON
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Credential | O.D.
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Telephone | 316-788-2020
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 1046-3
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License Number State | KS
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