MEDICARE: CHARLES DAVID GORDON M.D.

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	45189	AZ
2	2084N0400X	Neurology Physician	2012-01542	NC

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	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1265525372
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES DAVID GORDON M.D.

Provider Business Mailing Address
First Line	:	PO BOX 60447
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28260-0447
Country	:	US
Telephone Number	:	704-384-9437
Fax Number	:	704-384-9440

Provider Business Practice Location Address
First Line	:	6324 FAIRVIEW RD STE 400
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28210-4278
Country	:	US
Telephone Number	:	980-302-8626
Fax Number	:	980-302-8639

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

Provider Enumeration Date	:	10/02/2006
Last Update Date	:	06/11/2021

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