Provider Demographics
NPI:1992706683
Name:GORDON, PETER ALFRED (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:ALFRED
Last Name:GORDON
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:PO BOX 1798
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30031-1798
Mailing Address - Country:US
Mailing Address - Phone:404-292-2500
Mailing Address - Fax:404-294-9361
Practice Address - Street 1:1457 SCOTT BLVD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-1705
Practice Address - Country:US
Practice Address - Phone:404-292-2500
Practice Address - Fax:404-294-9361
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA023055207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00283786AMedicaid
GA00283786AMedicaid