Basic Information
| Provider Information | |||||||||
| NPI: | 1447770003 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | GRANT | ||||||||
| MiddleName: | THOMAS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1756 N BAYSHORE DR APT 15C | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331321138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742766786 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3501 JOHNSON ST | ||||||||
| Address2: | |||||||||
| City: | HOLLYWOOD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330215421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9549872000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2017 | ||||||||
| LastUpdateDate: | 12/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 007747 | AZ | N | Allopathic & Osteopathic Physicians | General Practice | 390200000X | 5101023568 | MI | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | OS18395 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.