Provider Demographics
NPI:1982892451
Name:ONSTAD, GORDON (MD)
Entity type:Individual
Prefix:
First Name:GORDON
Middle Name:
Last Name:ONSTAD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1960 NE 47TH ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-7708
Mailing Address - Country:US
Mailing Address - Phone:954-491-9010
Mailing Address - Fax:954-491-1009
Practice Address - Street 1:1960 NE 47TH ST
Practice Address - Street 2:SUITE 105
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-7708
Practice Address - Country:US
Practice Address - Phone:954-491-9010
Practice Address - Fax:954-491-1009
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-10
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME19304207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL71811Medicare PIN
D58199Medicare UPIN