=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902885908
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL A GORDON MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2006
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 117 DENNIS DRIVE
-----------------------------------------------------
City | SANFORD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-774-2220
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 117 DENNIS DRIVE
-----------------------------------------------------
City | SANFORD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-774-2220
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2086S0129X
-----------------------------------------------------
Taxonomy Name | Vascular Surgery Physician
-----------------------------------------------------
License Number | 13991
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 13991
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------