Provider Demographics
NPI:1144279548
Name:GORDON, CHARLES A (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:A
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 663
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30475-0663
Mailing Address - Country:US
Mailing Address - Phone:912-535-5555
Mailing Address - Fax:912-535-8930
Practice Address - Street 1:1 MEADOWS PKWY
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8759
Practice Address - Country:US
Practice Address - Phone:912-535-5555
Practice Address - Fax:912-535-8930
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA062039207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA066957OtherHIGHMARK PA BLUE SHIELD
PA01056706OtherCAPITAL BLUE CROSS
PA110097244OtherPALMETTO GBA MEDICARE
PA066957OtherHIGHMARK PA BLUE SHIELD
PA066957H9MMedicare PIN