Provider Demographics
NPI:1427083310
Name:GORDON, GAYLE (MD)
Entity type:Individual
Prefix:
First Name:GAYLE
Middle Name:
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 1:2909 MILITARY RD
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-2721
Mailing Address - Country:US
Mailing Address - Phone:501-778-4674
Mailing Address - Fax:501-778-4694
Practice Address - Street 1:2909 MILITARY RD
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-2721
Practice Address - Country:US
Practice Address - Phone:501-778-4674
Practice Address - Fax:501-778-4694
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-1397207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR132153001Medicaid
AR5K572OtherAR BCBS
AR5K572OtherAR BCBS
AR132153001Medicaid