Provider Demographics
NPI:1538272455
Name:GORDON, ADAM (OD)
Entity type:Individual
Prefix:DR
First Name:ADAM
Middle Name:
Last Name:GORDON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1716 UNIVERSITY BLVD
Mailing Address - Street 2:HPB G080A
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35294-0001
Mailing Address - Country:US
Mailing Address - Phone:205-934-4748
Mailing Address - Fax:205-934-6755
Practice Address - Street 1:1716 UNIVERSITY BLVD
Practice Address - Street 2:HPB G080A
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35294-0001
Practice Address - Country:US
Practice Address - Phone:205-934-4748
Practice Address - Fax:205-934-6755
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2010-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS574TA039152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02129061Medicaid
AL000059870Medicaid
AL410048451OtherMEDICARE RAIDROAD
LA1585971Medicaid
AL51059822OtherBCBS OF ALABAMA
P00280010OtherMEDICARE RAILROAD
ALT68916OtherVIVA
AL51059870OtherBCBS
AL000059870Medicaid
LA1585971Medicaid
MS02129061Medicaid
T68916Medicare UPIN
0279620003Medicare NSC