Provider Demographics
NPI:1053950303
Name:GORDON, BILLY (LP)
Entity type:Individual
Prefix:MR
First Name:BILLY
Middle Name:
Last Name:GORDON
Suffix:
Gender:M
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4001 ROSS AVE APT 111
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-5252
Mailing Address - Country:US
Mailing Address - Phone:321-217-9297
Mailing Address - Fax:
Practice Address - Street 1:4001 ROSS AVE APT 111
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-5252
Practice Address - Country:US
Practice Address - Phone:321-217-9297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-04
Last Update Date:2020-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1992224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist