Basic Information
| Provider Information | |||||||||
| NPI: | 1174815625 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1011 REED AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | WYOMISSING | ||||||||
| State: | PA | ||||||||
| PostalCode: | 196102002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103744401 | ||||||||
| FaxNumber: | 6103747140 | ||||||||
| Practice Location | |||||||||
| Address1: | 1011 REED AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | WYOMISSING | ||||||||
| State: | PA | ||||||||
| PostalCode: | 196102002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103744401 | ||||||||
| FaxNumber: | 6103747140 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2011 | ||||||||
| LastUpdateDate: | 03/31/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RG0100X | MD460173 | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
No ID Information.