Provider Demographics
NPI:1225039365
Name:NORDSTROM, DONALD GENE (MD)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:GENE
Last Name:NORDSTROM
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 1:836 E 65TH ST STE 22
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-4493
Mailing Address - Country:US
Mailing Address - Phone:912-819-2146
Mailing Address - Fax:
Practice Address - Street 1:100 BUCKWALTER PLACE BLVD STE 150
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29910-5023
Practice Address - Country:US
Practice Address - Phone:843-836-7120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA320282085R0001X
WI709132085R0001X
MN227422085R0202X
SC832052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1990903Medicaid
SC832059Medicaid
IA920005055OtherRR MEDICARE
IA49561OtherIA BLUESHIELD
IA1990903Medicaid