Provider Demographics
NPI:1306809272
Name:PAUL, GORDON RICHARD (MD)
Entity type:Individual
Prefix:
First Name:GORDON
Middle Name:RICHARD
Last Name:PAUL
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 1:720 HARRISON AVE STE 808
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2326
Mailing Address - Country:US
Mailing Address - Phone:617-638-5633
Mailing Address - Fax:617-638-8655
Practice Address - Street 1:720 HARRISON AVE STE 808
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2326
Practice Address - Country:US
Practice Address - Phone:617-638-5633
Practice Address - Fax:617-638-8655
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA30899207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2083167Medicaid
MAM07563Medicare ID - Type Unspecified
MA2083167Medicaid