MEDICARE: RICHARD G GORDY 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	SA51TA630	AL

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	51521264	OTHER	AL	BC

General Provider Information

NPI Number	:	1396776845
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD G GORDY OD

Provider Business Mailing Address
First Line	:	5009 RIVERCHASE DRIVE
Second Line	:	BUILDING 400 SUITE B
City	:	PHENIX CITY
State	:	AL
Zip	:	36867
Country	:	US
Telephone Number	:	334-291-5125
Fax Number	:

Provider Business Practice Location Address
First Line	:	5009 RIVER CHASE DR
Second Line	:	BLDG 100 SUITE C
City	:	PHENIX CITY
State	:	AL
Zip	:	36867-7425
Country	:	US
Telephone Number	:	334-291-5125
Fax Number	:	334-291-9956

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

Provider Enumeration Date	:	07/05/2006
Last Update Date	:	06/03/2019

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