Provider Demographics
NPI:1891354239
Name:GORDON, COLESON RJ
Entity type:Individual
Prefix:MR
First Name:COLESON
Middle Name:RJ
Last Name:GORDON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:880 LAKECREST AVE APT 1C
Mailing Address - Street 2:
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27265-2671
Mailing Address - Country:US
Mailing Address - Phone:219-707-0399
Mailing Address - Fax:
Practice Address - Street 1:880 LAKECREST AVE APT 1C
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27265-2671
Practice Address - Country:US
Practice Address - Phone:219-707-0399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-10
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program