MEDICARE: GORDON CLINIC-ANTONIO GORDON MD PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	0028982	FL
2	133N00000X	Nutritionist		FL
3	207RC0000X	Cardiovascular Disease Physician		FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	79262	OTHER	FL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1023002300
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GORDON CLINIC-ANTONIO GORDON MD PA

Provider Business Mailing Address
First Line	:	344 W 65TH ST
Second Line	:	SUITE 201-204
City	:	HIALEAH
State	:	FL
Zip	:	33012-6719
Country	:	US
Telephone Number	:	305-556-6459
Fax Number	:	305-556-9623

Provider Business Practice Location Address
First Line	:	344 W 65TH ST
Second Line	:	SUITE 201-204
City	:	HIALEAH
State	:	FL
Zip	:	33012-6719
Country	:	US
Telephone Number	:	305-556-6459
Fax Number	:	305-556-9623

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ANTONIO M. GORDON JR.
Credential	:	MD
Telephone Number	:	305-556-6459

Provider Enumeration Date	:	09/01/2005
Last Update Date	:	11/30/2010

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