Provider Demographics
NPI:1861417354
Name:GORDON, KATHLEEN P (DO)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:P
Last Name:GORDON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1524 ATWOOD AVE
Mailing Address - Street 2:SUITE 220
Mailing Address - City:JOHNSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02919
Mailing Address - Country:US
Mailing Address - Phone:401-272-1900
Mailing Address - Fax:401-453-3049
Practice Address - Street 1:1524 ATWOOD AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:JOHNSTON
Practice Address - State:RI
Practice Address - Zip Code:02919
Practice Address - Country:US
Practice Address - Phone:401-272-1900
Practice Address - Fax:401-453-3049
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI0482207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9020540Medicaid
402586OtherBLUE CHIP RI
0401976OtherUHP
20540OtherBCRI
RI9020540Medicaid
20540OtherBCRI
0401976OtherUHP