Individual
DR. GLENN GORDON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
2073 OLYMPIC ST, SPRINGFIELD, OR 97477
(541) 682-3550
Mailing address
2073 OLYMPIC ST, SPRINGFIELD, OR 97477-3413
(541) 682-3550
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
MD15934
OR
207Q00000X
Family Medicine Physician
MD15934
OR
208D00000X
General Practice Physician
Primary
MD15934
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
057141
—
OR
01
—
057221003
BCBS
—
01
—
76172
WASHINGTON L&I
—
05
—
8280034
—
WA
01
—
A018
CHAMPUS
—
01
—
C89984
LIPA
—
01
—
J0475-05
PACIFIC SOURCE
—
05
—
XPY185053
—
CA
Enumeration date
06/06/2006
Last updated
05/15/2018
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