NPIMap

Individual provider Active NPI

Gordon K Wang, MD

  • Family Medicine Physician
  • Punta Gorda, FL
National Provider Identifier
1174517205
Registry record updated Jun 23, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
ME0072508 Issued in FL
Practice address
100 Madrid Blvd
513
Punta Gorda, FL 33950-7968
Phone
(941) 505-0974
Fax
(941) 637-9000
NPI assigned
Sep 5, 2005
Last updated
Jun 23, 2011By the provider in NPPES
Sex
Male
Sole proprietor
Yes

NPPES NPI Registry

Updated by the provider on Jun 23, 2011

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X ME0072508 FL Primary

Addresses

Primary practice location

100 Madrid Blvd
513
Punta Gorda, FL 33950-7968

Mailing address

100 Madrid Blvd
513
Punta Gorda, FL 33950-7968
Phone (941) 505-0974

Other identifiers 2

IdentifierTypeStateIssuer
44390OtherFLBCBS
266939100MedicaidFL

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20041012001445 FL Practitioner - Family Practice 1658331848 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
Other, 1988
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
Legacy Healthcare Services IncGroup PAC ID 2163339722, shared by 46 NPIs, 3,431 clinicians

Practice addresses (Care Compare)

100 Madrid Blvd
Punta Gorda, FL 33950-7906

100 Madrid Blvd
Punta Gorda, FL 33950-8930
Phone (941) 505-8544

1499 S Brandywine Cir
Fort Myers, FL 33919-6775
Phone (239) 202-0059

7374 San Casa Dr
Englewood, FL 34224-8842
Phone (941) 417-5064

Hospital & facility affiliations

Procedures performed for Medicare patients

ProcedureNumber of procedures
Removal or shaving of skin growth1-10
Skin biopsy1-10

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
ME0072508FLMDFamily Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Burnt Store Family Medicine P L Family Medicine CurrentSince Apr 10, 2011 Accepting new patients
Punta Gorda Hma LLC Past Accepting new patients

Locations

100 Madrid Blvd
Unit 513
Punta Gorda, FL 33950
Phone (941) 505-0974

Interoperability endpoints

  • Direct secure messaging: gordon_wang@burnt-store-family-medicine-pl.amazing-direct.com
  • Direct secure messaging: gwang@burnt-store-family-medicine-pl.amazing-direct.com

Organizations & group practices 2

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 5

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1125878400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1308787200000",
    "number": "1174517205",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "100 MADRID BLVD",
            "address_2": "513",
            "city": "PUNTA GORDA",
            "state": "FL",
            "postal_code": "339507968",
            "telephone_number": "941-505-0974",
            "fax_number": "941-637-9000"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "100 MADRID BLVD",
            "address_2": "513",
            "city": "PUNTA GORDA",
            "state": "FL",
            "postal_code": "339507968",
            "telephone_number": "941-505-0974",
            "fax_number": "941-637-9000"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WANG",
        "first_name": "GORDON",
        "middle_name": "K",
        "name_prefix": "Dr.",
        "credential": "MD",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2005-09-05",
        "last_updated": "2011-06-23",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "FL",
            "license": "ME0072508",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "44390",
            "state": "FL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "266939100",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Punta Gorda, FL

Sources for this page

Verify at the official NPI Registry.