Provider Demographics
NPI:1447282355
Name:GORDON, CHARLES KENNETH (DO)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:KENNETH
Last Name:GORDON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1604 HOSPITAL PKWY
Mailing Address - Street 2:SUITE 409
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76022-6986
Mailing Address - Country:US
Mailing Address - Phone:871-283-1947
Mailing Address - Fax:817-283-2066
Practice Address - Street 1:1604 HOSPITAL PKWY
Practice Address - Street 2:SUITE 409
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76022-6986
Practice Address - Country:US
Practice Address - Phone:871-283-1947
Practice Address - Fax:817-283-2066
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXF6681207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXA66617Medicare UPIN