Basic Information
| Provider Information | |||||||||
| NPI: | 1770586919 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | JEFFERY | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 127 CRESTVIEW PARK DR | ||||||||
| Address2: | |||||||||
| City: | DICKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370552855 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154465121 | ||||||||
| FaxNumber: | 6154461357 | ||||||||
| Practice Location | |||||||||
| Address1: | 1300 SAWGRASS CORPORATE PARKWAY | ||||||||
| Address2: | STE 200 | ||||||||
| City: | SUNRISE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333232823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002433839 | ||||||||
| FaxNumber: | 8555275510 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2005 | ||||||||
| LastUpdateDate: | 12/16/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD11542 | TN | N | Allopathic & Osteopathic Physicians | Pediatrics | 208M00000X | 11542 | TN | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 3179587 | 05 | TN | MEDICAID | 4057650 | 01 | TN | BLUE CROSS BLUE SHIELD TN | OTHER | 370017664 | 01 | RAILROAD MEDICARE PIN | OTHER |