Provider Demographics
NPI:1992711469
Name:GORDON, STUART R (MD)
Entity type:Individual
Prefix:
First Name:STUART
Middle Name:R
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 1:1 MEDICAL CENTER DR
Mailing Address - Street 2:DARTMOUTH-HITCHCOCK MEDICAL CENTER
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03756-1000
Mailing Address - Country:US
Mailing Address - Phone:603-650-6472
Mailing Address - Fax:603-650-5225
Practice Address - Street 1:1 MEDICAL CENTER DR
Practice Address - Street 2:DARTMOUTH-HITCHCOCK MEDICAL CENTER
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03756-1000
Practice Address - Country:US
Practice Address - Phone:603-650-6472
Practice Address - Fax:603-650-5225
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH8459207RG0100X, 207RI0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207RI0008XAllopathic & Osteopathic PhysiciansInternal MedicineHepatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH80003150Medicaid
VT0RE3150Medicaid
VT0RE3150Medicaid
NHRE315002Medicare PIN
NHRE315001Medicare PIN