Provider Demographics
NPI:1528050069
Name:GORDON, WILLIAM DAVID (OD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:DAVID
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 1:3000 FORSYTHE AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-3012
Mailing Address - Country:US
Mailing Address - Phone:318-325-9474
Mailing Address - Fax:318-388-1868
Practice Address - Street 1:3000 FORSYTHE AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-3012
Practice Address - Country:US
Practice Address - Phone:318-325-9474
Practice Address - Fax:318-388-1868
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA909-230T152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 152WS0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Not Answered152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Not Answered152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Not Answered152WS0006XEye and Vision Services ProvidersOptometristSports Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1337170Medicaid
LA47505Medicare ID - Type Unspecified
LA1337170Medicaid