Provider Demographics
NPI:1306813274
Name:GORDON, HEIDI V (MD)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:V
Last Name:GORDON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 NEWBURYPORT RD
Mailing Address - Street 2:
Mailing Address - City:UPPER HOLLAND
Mailing Address - State:PA
Mailing Address - Zip Code:19053-1556
Mailing Address - Country:US
Mailing Address - Phone:215-860-4110
Mailing Address - Fax:267-295-8208
Practice Address - Street 1:1 COOPER PLZ
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08103-1461
Practice Address - Country:US
Practice Address - Phone:856-342-2425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD054695L207L00000X
NJMA62314207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7205007Medicaid
852293Medicare ID - Type Unspecified
NJ031896CK2Medicare PIN
G24251Medicare UPIN