Provider Demographics
NPI:1144452798
Name:GORDON, ROBERT K (DO)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:K
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 1:400 W CAMELBACK RD
Mailing Address - Street 2:SUITE 209
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-2330
Mailing Address - Country:US
Mailing Address - Phone:928-514-9433
Mailing Address - Fax:
Practice Address - Street 1:400 W CAMELBACK RD
Practice Address - Street 2:SUITE 209
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-2330
Practice Address - Country:US
Practice Address - Phone:928-514-9433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-17
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVSL0746208000000X
MI5101018505207Q00000X
AZ006491208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ006491OtherARIZONA BOARD OF OSTEOPATHIC EXAMINERS