Provider Demographics
NPI:1144272618
Name:GORDON, HEIDI MARIE (OD)
Entity type:Individual
Prefix:DR
First Name:HEIDI
Middle Name:MARIE
Last Name:GORDON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5157 CLEAR RIDGE DR SE
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:MI
Mailing Address - Zip Code:49301-8365
Mailing Address - Country:US
Mailing Address - Phone:616-868-0703
Mailing Address - Fax:
Practice Address - Street 1:2186 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MI
Practice Address - Zip Code:49331-8637
Practice Address - Country:US
Practice Address - Phone:616-897-2020
Practice Address - Fax:616-897-2041
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004101152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU88147Medicare UPIN
MI0N40470Medicare ID - Type Unspecified