Provider Demographics
NPI:1982596607
Name:GORDON, MARK ROBERT ANDREW
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ROBERT ANDREW
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 1:1910 FAIRGROVE AVE STE E
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:OH
Mailing Address - Zip Code:45011-1930
Mailing Address - Country:US
Mailing Address - Phone:513-494-4679
Mailing Address - Fax:
Practice Address - Street 1:1805 DALTON AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45214-2055
Practice Address - Country:US
Practice Address - Phone:513-494-4649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-17
Last Update Date:2025-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator