Provider Demographics
NPI:1447062229
Name:GORDON, GUY (PRS)
Entity type:Individual
Prefix:
First Name:GUY
Middle Name:
Last Name:GORDON
Suffix:
Gender:M
Credentials:PRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12115 SHERATON LN
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45246-1613
Mailing Address - Country:US
Mailing Address - Phone:513-403-7732
Mailing Address - Fax:
Practice Address - Street 1:12115 SHERATON LN
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45246-1613
Practice Address - Country:US
Practice Address - Phone:513-904-1646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-21
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPS.005748175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist