Basic Information
| Provider Information | |||||||||
| NPI: | 1235368945 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | LONNA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D., PHARM D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10140 CENTURION PKWY N FL PROVIDER | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322560532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046973600 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 13535 NEMOURS PKWY | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4075674000 | ||||||||
| FaxNumber: | 4075675924 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2009 | ||||||||
| LastUpdateDate: | 12/31/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/31/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME135539 | FL | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | C1-0013322 | DE | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080A0000X | ME135539 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine |
ID Information
| ID | Type | State | Issuer | Description | 024920900 | 05 | FL | MEDICAID |