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General NPI Number Information
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NPI Number | 1427077213
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Entity Type | Individual
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Provider Name | GLENN L GORDON MD
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Gender | Male
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Dates
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Enumeration Date | 07/19/2006
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Last Update Date | 10/28/2020
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Provider Practice Location Address
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Address Line | 714 MEDICAL PARK DR
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City | MEXICO
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State | MO
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Zip | 65265-3726
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Country | US
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Telephone | 573-590-1553
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Fax | 877-958-7717
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Provider Business Mailing Address
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Address Line | 714 MEDICAL PARK DR
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City | MEXICO
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State | MO
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Zip | 65265-3726
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Country | US
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Telephone | 573-590-1553
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number | 036067470
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number | R1H39
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License Number State | MO
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