Basic Information
| Provider Information | |||||||||
| NPI: | 1689684888 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | ANTONIO | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 102 IRVING ST NW | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200102921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2028771000 | ||||||||
| FaxNumber: | 2022915366 | ||||||||
| Practice Location | |||||||||
| Address1: | 102 IRVING ST NW | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200102921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2028771000 | ||||||||
| FaxNumber: | 2022915366 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 12/11/2007 | ||||||||
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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 | 103TC0700X | PSY 1528 | DC | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 247626 | 01 | MAMSI | OTHER | 5681292 | 01 | AETNA NON HMO | OTHER | DC 2528584 | 01 | AETNA HMO | OTHER | 103645 | 01 | KAISER | OTHER | SMD 3839272 | 01 | AETNA HMO | OTHER | H360-0004 | 01 | BS NCA | OTHER | 512762 | 01 | NCPPO | OTHER |