Provider Demographics
NPI:1750486858
Name:GORDON, WAYNE HOUSTON (MD)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:HOUSTON
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 1:9015 BOARDWALK PL
Mailing Address - Street 2:
Mailing Address - City:MANVEL
Mailing Address - State:TX
Mailing Address - Zip Code:77578-2307
Mailing Address - Country:US
Mailing Address - Phone:210-725-9179
Mailing Address - Fax:
Practice Address - Street 1:1000 JOHNSON FERRY RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1606
Practice Address - Country:US
Practice Address - Phone:404-851-8000
Practice Address - Fax:404-303-3759
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2025-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH351227082084N0400X
GA1013432084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0986747Medicaid
OHH353801Medicare PIN
TX83741FMedicare ID - Type Unspecified
TX74-2842145OtherTAX-ID