MEDICARE: MICHAEL B GORDON OD

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	152W00000X	Optometrist	530	NH

General Provider Information

NPI Number	:	1265433429
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL B GORDON OD

Provider Business Mailing Address
First Line	:	9 MAIN ST
Second Line	:
City	:	PETERBOROUGH
State	:	NH
Zip	:	03458-2417
Country	:	US
Telephone Number	:	603-924-1611
Fax Number	:	603-924-1609

Provider Business Practice Location Address
First Line	:	9 MAIN ST
Second Line	:
City	:	PETERBOROUGH
State	:	NH
Zip	:	03458-2417
Country	:	US
Telephone Number	:	603-924-1611
Fax Number	:	603-924-1609

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/09/2005
Last Update Date	:	07/08/2007

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