Provider Demographics
NPI:1316917123
Name:GORDON, MICHAEL W (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:W
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 1:214 N. BDWY
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55975
Mailing Address - Country:US
Mailing Address - Phone:507-346-7555
Mailing Address - Fax:507-346-7555
Practice Address - Street 1:214 N. BDWY
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55975
Practice Address - Country:US
Practice Address - Phone:507-346-7555
Practice Address - Fax:507-346-7555
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-24
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1979000152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN318262200Medicaid
MN0316200001Medicare NSC
MN318262200Medicaid
MNT39860Medicare UPIN