Provider Demographics
NPI:1760227367
Name:GORDON, ETHAN BENJAMIN (MD)
Entity type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:BENJAMIN
Last Name:GORDON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 N WASHINGTON AVE APT 503
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48607-1298
Mailing Address - Country:US
Mailing Address - Phone:847-707-0413
Mailing Address - Fax:
Practice Address - Street 1:1575 CONCENTRIC BLVD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604-9311
Practice Address - Country:US
Practice Address - Phone:989-746-7766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-26
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4351053528207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine