Provider Demographics
NPI:1306888334
Name:GORDON, CAROLE LYNN (MD)
Entity type:Individual
Prefix:
First Name:CAROLE
Middle Name:LYNN
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 1:12109 COUNTY ROAD 103
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:FL
Mailing Address - Zip Code:34484-2951
Mailing Address - Country:US
Mailing Address - Phone:352-205-8981
Mailing Address - Fax:352-391-6498
Practice Address - Street 1:12109 COUNTY ROAD 103 STE 2
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:FL
Practice Address - Zip Code:34484-2951
Practice Address - Country:US
Practice Address - Phone:352-259-4400
Practice Address - Fax:352-787-0370
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG2973208800000X, 2088P0231X
FLME 110346208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric Urology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX032766001Medicaid
TXB87908Medicare UPIN
FLFD554ZMedicare PIN
TX032766001Medicaid
TX0772260001Medicare NSC