Provider Demographics
NPI:1730429622
Name:GORDON, ANDREW
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:GORDON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22203 CHESAPEAKE CIR
Mailing Address - Street 2:
Mailing Address - City:WALLED LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48390-5916
Mailing Address - Country:US
Mailing Address - Phone:816-646-9900
Mailing Address - Fax:
Practice Address - Street 1:2020 59TH ST W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-4604
Practice Address - Country:US
Practice Address - Phone:941-792-6611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-28
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLOS16236207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program