Provider Demographics
NPI:1225086747
Name:HOLEN, GORDON NIEL (DO)
Entity type:Individual
Prefix:DR
First Name:GORDON
Middle Name:NIEL
Last Name:HOLEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2263 SANDSTONE DRIVE
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37814
Mailing Address - Country:US
Mailing Address - Phone:727-480-7901
Mailing Address - Fax:865-774-4868
Practice Address - Street 1:2263 SANDSTONE DRIVE
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37814
Practice Address - Country:US
Practice Address - Phone:865-774-4440
Practice Address - Fax:865-774-4868
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2957207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1529874Medicaid
TN103I203555Medicare PIN