Provider Demographics
NPI:1053316174
Name:ABERNATHIE, GORDON (DO)
Entity type:Individual
Prefix:
First Name:GORDON
Middle Name:
Last Name:ABERNATHIE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5410 SHERIDAN LAKE RD
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-9208
Mailing Address - Country:US
Mailing Address - Phone:605-348-4141
Mailing Address - Fax:605-342-7880
Practice Address - Street 1:5410 SHERIDAN LAKE RD
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-9208
Practice Address - Country:US
Practice Address - Phone:605-348-4141
Practice Address - Fax:605-342-7880
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD2799207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
S103292Medicare PIN