Provider Demographics
NPI:1285776294
Name:GORDON, GREGORY K (OD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:K
Last Name:GORDON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:471 US 231 S
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47546
Mailing Address - Country:US
Mailing Address - Phone:812-634-9887
Mailing Address - Fax:812-634-9888
Practice Address - Street 1:471 US 231 S
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:IN
Practice Address - Zip Code:47546
Practice Address - Country:US
Practice Address - Phone:812-634-9887
Practice Address - Fax:812-634-9888
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002168B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0779080001Medicare NSC
INU24824Medicare UPIN