Provider Demographics
NPI:1215935754
Name:GORDY, DENNIS DEWAYNE (MD)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:DEWAYNE
Last Name:GORDY
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:PO BOX 420
Mailing Address - Street 2:1721 W 18TH ST
Mailing Address - City:SPENCER
Mailing Address - State:IA
Mailing Address - Zip Code:51301-0420
Mailing Address - Country:US
Mailing Address - Phone:712-262-8878
Mailing Address - Fax:712-262-8807
Practice Address - Street 1:1721 W 18TH ST
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:IA
Practice Address - Zip Code:51301
Practice Address - Country:US
Practice Address - Phone:712-262-8878
Practice Address - Fax:712-262-8807
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2007-07-08
Deactivation Date:2006-03-15
Deactivation Code:
Reactivation Date:2006-03-21
Provider Licenses
StateLicense IDTaxonomies
IA19347207W00000X
MN33427207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0148312Medicaid
A01300Medicare UPIN
IA0148312Medicaid