Provider Demographics
NPI:1497183404
Name:GORDON, MARK
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:GORDON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 N UNIVERSITY DR STE A106
Mailing Address - Street 2:
Mailing Address - City:LAUDERHILL
Mailing Address - State:FL
Mailing Address - Zip Code:33351-6243
Mailing Address - Country:US
Mailing Address - Phone:786-273-0728
Mailing Address - Fax:954-639-7433
Practice Address - Street 1:4300 N UNIVERSITY DR STE A106
Practice Address - Street 2:
Practice Address - City:LAUDERHILL
Practice Address - State:FL
Practice Address - Zip Code:33351-6243
Practice Address - Country:US
Practice Address - Phone:786-273-0728
Practice Address - Fax:954-639-7433
Is Sole Proprietor?:No
Enumeration Date:2013-10-30
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11017993363LC1500X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity Health