Individual
DR. KENNETH BRYCE GORDON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
OD
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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