Basic Information
| Provider Information | |||||||||
| NPI: | 1144397217 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2400 | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329022400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8667441461 | ||||||||
| FaxNumber: | 7706213181 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 W COCOA BEACH CSWY | ||||||||
| Address2: | |||||||||
| City: | COCOA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329313585 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217997111 | ||||||||
| FaxNumber: | 7706213181 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| LastUpdateDate: | 08/05/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | ME64194 | FL | N | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085N0904X | ME64194 | FL | N | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085P0229X | ME64194 | FL | N | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085R0202X | ME64194 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | ME64194 | FL | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085U0001X | ME64194 | FL | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound |
ID Information
| ID | Type | State | Issuer | Description | 23388 | 01 | FL | BCBS | OTHER | 300048844 | 01 | MEDICARE RR | OTHER | 23388Z | 01 | FL | MEDICARE PTAN | OTHER | 377261600 | 05 | FL | MEDICAID |