Basic Information
| Provider Information | |||||||||
| NPI: | 1417940552 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | GAIL | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COX | ||||||||
| OtherFirstName: | GAIL | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | O.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 225 E LEE AVE | ||||||||
| Address2: | |||||||||
| City: | YADKINVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270558227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3366792931 | ||||||||
| FaxNumber: | 3366776486 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 E LEE AVE | ||||||||
| Address2: | |||||||||
| City: | YADKINVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3366792931 | ||||||||
| FaxNumber: | 3366776486 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2005 | ||||||||
| LastUpdateDate: | 07/16/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1931 | NC | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1931 | 01 | NC | OD LICENSE | OTHER | 2474157B | 01 | MEDICARE - YADKINVILLE | OTHER | 511078 | 01 | OE TRACKER | OTHER | 2474157C | 01 | MEDICARE - EAST BEND | OTHER | 5905423 | 05 | NC | MEDICAID | MC1164158 | 01 | DEA | OTHER | 1417940552 | 01 | NPI | OTHER |