MEDICARE: DR. KENNETH BRYCE 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	0618000495	VA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DA5536	OTHER	VA	RAILROAD MEDICARE PIN
2	U84594	OTHER	VA	RAILROAD MEDICARE UPIN
3	541783118	OTHER	VA	RAILROAD MEDICARE TAX ID
5	541783118	OTHER		MEDICARE TAX ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	P00068065	OTHER	VA	RAILROAD PROVIDER

General Provider Information

NPI Number	:	1497752208
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH BRYCE GORDON OD

Provider Business Mailing Address
First Line	:	4811 S LABURNUM AVE
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23231-2713
Country	:	US
Telephone Number	:	804-226-1144
Fax Number	:	804-236-9026

Provider Business Practice Location Address
First Line	:	4811 S LABURNUM AVE
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23231-2713
Country	:	US
Telephone Number	:	804-226-1144
Fax Number	:	804-236-9026

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

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	05/21/2013

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Directions to “ DR. KENNETH BRYCE GORDON OD” Practice Location

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