Provider Demographics
NPI:1427077213
Name:GORDON, GLENN L (MD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:L
Last Name:GORDON
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 1:714 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:MEXICO
Mailing Address - State:MO
Mailing Address - Zip Code:65265-3726
Mailing Address - Country:US
Mailing Address - Phone:573-590-1553
Mailing Address - Fax:
Practice Address - Street 1:714 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:MO
Practice Address - Zip Code:65265-3726
Practice Address - Country:US
Practice Address - Phone:573-590-1553
Practice Address - Fax:877-958-7717
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036067470207RG0100X
MOR1H39207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0010137OtherMEDICARE #
MOR1H39OtherMISSOURI LICENSE NUMBER
MO0010137OtherMEDICARE #