Provider Demographics
NPI:1124102678
Name:GORDON, SANFORD (MD)
Entity type:Individual
Prefix:DR
First Name:SANFORD
Middle Name:
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 1:788 ELM SPRING RD
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15243-1004
Mailing Address - Country:US
Mailing Address - Phone:412-561-8966
Mailing Address - Fax:412-561-3249
Practice Address - Street 1:788 ELM SPRING RD
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15243-1004
Practice Address - Country:US
Practice Address - Phone:412-561-8966
Practice Address - Fax:412-561-3249
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA05001753L2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA428939OtherBLUE SHIELD
PA05001753LOtherLICENSE NUMBER
PAC33972Medicare UPIN
PA428939Medicare ID - Type Unspecified