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NPI Code Detail

MEDICARE: DR. JUSTIN R GORDON OD

MEDICARE: DR. JUSTIN R 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
1152W00000XOptometrist046006849IL

General Provider Information

NPI Number : 1366459711
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. JUSTIN R GORDON OD
Provider Business Mailing Address
First Line : 3143 W DEVON AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60659-1424
Country : US
Telephone Number : 773-764-5300
Fax Number : 773-764-2810
Provider Business Practice Location Address
First Line : 3143 W DEVON AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60659-1424
Country : US
Telephone Number : 773-764-5300
Fax Number : 773-764-2810
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/01/2006
Last Update Date : 07/07/2011

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