Provider Demographics
NPI:1093868051
Name:GORDON, JOHN EDWARD (MD)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:EDWARD
Last Name:GORDON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 W. IRONWOOD
Mailing Address - Street 2:SUITE # 306
Mailing Address - City:COEUR D' ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814
Mailing Address - Country:US
Mailing Address - Phone:208-651-1335
Mailing Address - Fax:208-765-0779
Practice Address - Street 1:1200 W. IRONWOOD
Practice Address - Street 2:SUITE # 306
Practice Address - City:COEUR D' ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814
Practice Address - Country:US
Practice Address - Phone:208-651-1335
Practice Address - Fax:208-765-0779
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-20
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-62132084P0800X, 2084P0804X
IDIDAHOM-62132084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID001185400Medicaid
ID1127512Medicare ID - Type Unspecified