Provider Demographics
NPI:1679626923
Name:GORDON, ROBERT L (PHD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:L
Last Name:GORDON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5174 BLAZER PARKWAY
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017
Mailing Address - Country:US
Mailing Address - Phone:614-792-9104
Mailing Address - Fax:614-792-2382
Practice Address - Street 1:5174 BLAZER PARKWAY
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017
Practice Address - Country:US
Practice Address - Phone:614-792-9104
Practice Address - Fax:614-792-2382
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4346103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
113095OtherMHN
0026591OtherTRICARE
OH0815523Medicaid
542647OtherANHEUSER BUSCH
000000119574OtherANTHEM BC BS
OH0815523Medicaid