MEDICARE: MINOR W GORDON PH D PC

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	251S00000X	Community/Behavioral Health Agency	309	OK

General Provider Information

NPI Number	:	1740466200
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINOR W GORDON PH D PC

Provider Business Mailing Address
First Line	:	3223 E 31ST ST
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74105-2452
Country	:	US
Telephone Number	:	918-747-5308
Fax Number	:

Provider Business Practice Location Address
First Line	:	3223 E 31ST ST
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74105-2452
Country	:	US
Telephone Number	:	918-747-5308
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MINOR WILLIAM GORDON
Credential	:	PH D
Telephone Number	:	918-747-5308

Provider Enumeration Date	:	01/15/2008
Last Update Date	:	01/15/2008

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