Provider Demographics
NPI:1215992029
Name:GORDON, ELY R (DO, MPH)
Entity type:Individual
Prefix:DR
First Name:ELY
Middle Name:R
Last Name:GORDON
Suffix:
Gender:M
Credentials:DO, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5012 S US HWY 75, SUITE 300
Mailing Address - Street 2:ATTN BILLING
Mailing Address - City:DENISON
Mailing Address - State:TX
Mailing Address - Zip Code:75020-4589
Mailing Address - Country:US
Mailing Address - Phone:580-795-5506
Mailing Address - Fax:580-795-5145
Practice Address - Street 1:500 BROOKSIDE DRIVE
Practice Address - Street 2:PO BOX 847
Practice Address - City:MADILL
Practice Address - State:OK
Practice Address - Zip Code:73446-0847
Practice Address - Country:US
Practice Address - Phone:580-795-5506
Practice Address - Fax:580-795-5145
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO 621207R00000X, 208000000X
MO2006023036208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
0411221OtherUNITED HEALTHCARE
110187817OtherRR MEDICARE
AL000008373Medicaid
51008373OtherBCBS
110187817OtherRR MEDICARE
000008373Medicare ID - Type Unspecified