Provider Demographics
NPI:1447266176
Name:GORDON, COLETTE (MD)
Entity type:Individual
Prefix:
First Name:COLETTE
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 N SHERIDAN RD STE 101
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-6162
Mailing Address - Country:US
Mailing Address - Phone:773-281-7835
Mailing Address - Fax:
Practice Address - Street 1:2800 N SHERIDAN RD STE 101
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-6162
Practice Address - Country:US
Practice Address - Phone:773-281-7835
Practice Address - Fax:773-281-8736
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036052490207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036052490Medicaid
IL036052490Medicaid
745950Medicare PIN