Basic Information
| Provider Information | |||||||||
| NPI: | 1356401749 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | CECILIA | ||||||||
| MiddleName: | BERNADETTE | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2620 NEW BERN AVE | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276101821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198333111 | ||||||||
| FaxNumber: | 9198323112 | ||||||||
| Practice Location | |||||||||
| Address1: | 212 S SALEM ST | ||||||||
| Address2: | |||||||||
| City: | APEX | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275021825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193625201 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2006 | ||||||||
| LastUpdateDate: | 09/28/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OS9461 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 200301233 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | OS9461 | 01 | FL | MEDICAL LICENSE | OTHER | 89135MO | 05 | NC | MEDICAID |