Provider Demographics
NPI:1871549204
Name:GORDON, KENNETH D (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:D
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 1:1602 VERNON RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-4100
Mailing Address - Country:US
Mailing Address - Phone:706-882-9341
Mailing Address - Fax:706-884-0131
Practice Address - Street 1:1602 VERNON RD
Practice Address - Street 2:SUITE 400
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4100
Practice Address - Country:US
Practice Address - Phone:706-882-9341
Practice Address - Fax:706-884-0131
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA037816207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100064937AMedicaid
GA100064937AMedicaid
GA11SCFSSMedicare PIN