Provider Demographics
NPI:1871556977
Name:MATHES, GORDON L (MD)
Entity type:Individual
Prefix:DR
First Name:GORDON
Middle Name:L
Last Name:MATHES
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 1:2000 PERIMETER PARK DR STE 200
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27560-8442
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:180 FOY DR
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-2417
Practice Address - Country:US
Practice Address - Phone:252-443-3136
Practice Address - Fax:252-443-3847
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC27063208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8954719Medicaid
NC208557AOtherMEDICARE UNSPECIFIED
NCC85351Medicare UPIN
NC1013970136Medicare NSC