Provider Demographics
NPI:1063440899
Name:GORDON, ALFRED Y (MD)
Entity type:Individual
Prefix:
First Name:ALFRED
Middle Name:Y
Last Name:GORDON
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1523
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72702-1523
Mailing Address - Country:US
Mailing Address - Phone:479-571-6038
Mailing Address - Fax:479-582-0222
Practice Address - Street 1:688 E MILLSAP RD STE 101
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-3930
Practice Address - Country:US
Practice Address - Phone:479-443-3536
Practice Address - Fax:479-443-3933
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2025-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-0004207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5J347OtherAR BC/BS
AR124897001Medicaid
ARP00304738OtherRR MCR
AR124897001Medicaid
AR5J347B836Medicare PIN
ARF76517Medicare UPIN