Provider Demographics
NPI:1992891584
Name:GORDON, DREXEL REED (DO)
Entity type:Individual
Prefix:
First Name:DREXEL
Middle Name:REED
Last Name:GORDON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 DEPOT ST
Mailing Address - Street 2:STE 2
Mailing Address - City:BRIDGTON
Mailing Address - State:ME
Mailing Address - Zip Code:04009-1368
Mailing Address - Country:US
Mailing Address - Phone:207-647-5499
Mailing Address - Fax:207-647-5931
Practice Address - Street 1:8 DEPOT ST
Practice Address - Street 2:STE 2
Practice Address - City:BRIDGTON
Practice Address - State:ME
Practice Address - Zip Code:04009-1368
Practice Address - Country:US
Practice Address - Phone:207-647-5499
Practice Address - Fax:207-647-5931
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1454207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME234110099Medicaid
ME234110099Medicaid
MEMM5484Medicare ID - Type Unspecified