Provider Demographics
NPI:1871597666
Name:GORDON, KEVIN R (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:R
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 1:505 OMEGA DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76014-2004
Mailing Address - Country:US
Mailing Address - Phone:817-468-3255
Mailing Address - Fax:817-468-7823
Practice Address - Street 1:3201 MATLOCK RD STE 350
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76015-2954
Practice Address - Country:US
Practice Address - Phone:817-468-3255
Practice Address - Fax:817-468-7823
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2024-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1868207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX147253202Medicaid
TX147253202Medicaid
TX8886K1Medicare ID - Type Unspecified