Provider Demographics
NPI:1679516124
Name:GORDON, CHARLES S (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:S
Last Name:GORDON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1508
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34284-1508
Mailing Address - Country:US
Mailing Address - Phone:941-488-7781
Mailing Address - Fax:941-484-9235
Practice Address - Street 1:512 NOKOMIS AVE S
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-2817
Practice Address - Country:US
Practice Address - Phone:941-488-7781
Practice Address - Fax:941-484-9235
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00688122085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL265320600Medicaid
H36392Medicare UPIN
FLE5522YMedicare PIN