Provider Demographics
NPI:1598716698
Name:GORDON, MARILYN (MD)
Entity type:Individual
Prefix:
First Name:MARILYN
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 1:65 LIBBY ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-2992
Mailing Address - Country:US
Mailing Address - Phone:508-584-6060
Mailing Address - Fax:508-584-4949
Practice Address - Street 1:65 LIBBY ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-2992
Practice Address - Country:US
Practice Address - Phone:508-584-6060
Practice Address - Fax:508-584-4949
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA81230207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA761592OtherTUFTS HEALTH
MA65042OtherHARVARD PILGRIM
MA3144500Medicaid
MA761592OtherTUFTS HEALTH
MA65042OtherHARVARD PILGRIM