Provider Demographics
NPI:1386602464
Name:GORDON, ANTHONY ROY (DPM)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:ROY
Last Name:GORDON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 CLUB ESTATES CT
Mailing Address - Street 2:
Mailing Address - City:STATHAM
Mailing Address - State:GA
Mailing Address - Zip Code:30666-2659
Mailing Address - Country:US
Mailing Address - Phone:706-208-9977
Mailing Address - Fax:949-955-7016
Practice Address - Street 1:230 CEDAR POINTE DR
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30605-3339
Practice Address - Country:US
Practice Address - Phone:706-208-9977
Practice Address - Fax:949-955-7016
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-01
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA00827213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00807661AMedicaid
48SCBZQMedicare PIN
GA00807661AMedicaid
GA4557530001Medicare NSC