Basic Information
| Provider Information | |||||||||
| NPI: | 1164450300 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GITLIN | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1999 MARCUS AVE | ||||||||
| Address2: | SUITE M18 | ||||||||
| City: | NEW HYDE PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110421017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5164666953 | ||||||||
| FaxNumber: | 5164665608 | ||||||||
| Practice Location | |||||||||
| Address1: | 247 ROUTE 100 | ||||||||
| Address2: | SUITE 1002 | ||||||||
| City: | SOMERS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105893231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9149628290 | ||||||||
| FaxNumber: | 9149628851 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 01/29/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 203315 | NY | Y | Allopathic & Osteopathic Physicians | Urology | 2088P0231X | 203315 | NY | N | Allopathic & Osteopathic Physicians | Urology | Pediatric Urology |
ID Information
| ID | Type | State | Issuer | Description | 02298126 | 05 | NY | MEDICAID |