Basic Information
| Provider Information | |||||||||
| NPI: | 1871597666 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 505 OMEGA DR | ||||||||
| Address2: | |||||||||
| City: | ARLINGTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760142004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174683255 | ||||||||
| FaxNumber: | 8174687823 | ||||||||
| Practice Location | |||||||||
| Address1: | 505 OMEGA DR | ||||||||
| Address2: | |||||||||
| City: | ARLINGTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760142004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174683255 | ||||||||
| FaxNumber: | 8174687823 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2005 | ||||||||
| LastUpdateDate: | 03/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | L1868 | TX | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 147253202 | 05 | TX | MEDICAID |