Provider Demographics
NPI:1174517205
Name:WANG, GORDON K (MD)
Entity type:Individual
Prefix:DR
First Name:GORDON
Middle Name:K
Last Name:WANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:100 MADRID BLVD
Mailing Address - Street 2:513
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33950-7968
Mailing Address - Country:US
Mailing Address - Phone:941-505-0974
Mailing Address - Fax:941-637-9000
Practice Address - Street 1:100 MADRID BLVD
Practice Address - Street 2:513
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33950-7968
Practice Address - Country:US
Practice Address - Phone:941-505-0974
Practice Address - Fax:941-637-9000
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-05
Last Update Date:2011-06-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME0072508207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL44390OtherBCBS
FL266939100Medicaid
FL44390WMedicare PIN
FL266939100Medicaid
FLF83855Medicare UPIN
FL080190819Medicare ID - Type UnspecifiedRAILROAD MEDICARE