Provider Demographics
NPI:1699870212
Name:GORDON, MICHAEL D (OD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
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 1:8100 E 22ND ST N
Mailing Address - Street 2:BLDG 1600
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226
Mailing Address - Country:US
Mailing Address - Phone:316-684-2020
Mailing Address - Fax:316-686-7307
Practice Address - Street 1:8100 E 22ND ST N
Practice Address - Street 2:BLDG 1600
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226
Practice Address - Country:US
Practice Address - Phone:316-684-2020
Practice Address - Fax:316-686-7307
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS10462152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0254820002OtherCIGNA MEDICARE
0254820002OtherCIGNA MEDICARE
T43633Medicare UPIN
651032Medicare ID - Type UnspecifiedBCBS
18069Medicare ID - Type UnspecifiedBCBS
005057Medicare ID - Type UnspecifiedBCBS