Basic Information
| Provider Information | |||||||||
| NPI: | 1124177167 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | HART | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2101 E JEFFERSON ST | ||||||||
| Address2: | KAISER PERMANENTE MEDICARE ENROLLMENT | ||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208524908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018162424 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10810 CONNECTICUT AVE | ||||||||
| Address2: | KAISER PERMANENTE KENSINGTON MEDICAL CENTER | ||||||||
| City: | KENSINGTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208952138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3019297100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2007 | ||||||||
| LastUpdateDate: | 01/18/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MD17505 | DC | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 0101041082 | VA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | D36724 | MD | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 800016054 | 05 | MD | MEDICAID |