Provider Demographics
NPI:1043256340
Name:GORDON, MARVIN RALPH (MD)
Entity type:Individual
Prefix:
First Name:MARVIN
Middle Name:RALPH
Last Name:GORDON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4740 DICKINSON WAY
Mailing Address - Street 2:
Mailing Address - City:DOYLESTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18902-6522
Mailing Address - Country:US
Mailing Address - Phone:215-794-2528
Mailing Address - Fax:267-544-0105
Practice Address - Street 1:4740 DICKINSON WAY
Practice Address - Street 2:
Practice Address - City:DOYLESTOWN
Practice Address - State:PA
Practice Address - Zip Code:18902-6522
Practice Address - Country:US
Practice Address - Phone:215-794-2528
Practice Address - Fax:267-544-0105
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-032073-E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1049356Medicaid
PAC32948Medicare UPIN
PA181265Medicare ID - Type Unspecified