Basic Information
| Provider Information | |||||||||
| NPI: | 1558459008 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | MARC | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 175 COMMUNITY DR | ||||||||
| Address2: | |||||||||
| City: | GREAT NECK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110215502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5164651900 | ||||||||
| FaxNumber: | 5164651830 | ||||||||
| Practice Location | |||||||||
| Address1: | 611 NORTHERN BLVD | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | GREAT NECK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110215207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5163257000 | ||||||||
| FaxNumber: | 5163257001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 09/11/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 167360 | NY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 01189591 | 05 | NY | MEDICAID |