Individual
DR. KENNETH BRYCE GORDON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
OD
Contact information
Practice address
4811 S LABURNUM AVE, RICHMOND, VA 23231-2713
(804) 226-1144
(804) 236-9026
Mailing address
4811 S LABURNUM AVE, RICHMOND, VA 23231-2713
(804) 226-1144
(804) 236-9026
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
0618000495
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
541783118
RAILROAD MEDICARE TAX ID
VA
01
—
541783118
MEDICARE TAX ID
—
05
—
9232362
—
VA
01
—
DA5536
RAILROAD MEDICARE PIN
VA
01
—
P00068065
RAILROAD PROVIDER
VA
01
—
U84594
RAILROAD MEDICARE UPIN
VA
Enumeration date
07/07/2005
Last updated
05/21/2013
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