Basic Information
Provider Information | |||||||||
NPI: | 1841350428 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | JOEL GORDON, MD | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 910 | ||||||||
Address2: |   | ||||||||
City: | GREENFIELD | ||||||||
State: | MA | ||||||||
PostalCode: | 013020910 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4137728500 | ||||||||
FaxNumber: | 4137728900 | ||||||||
Practice Location | |||||||||
Address1: | 33 RIDDELL ST STE 4 | ||||||||
Address2: |   | ||||||||
City: | GREENFIELD | ||||||||
State: | MA | ||||||||
PostalCode: | 013012008 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4137747900 | ||||||||
FaxNumber: | 4137747901 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/12/2006 | ||||||||
LastUpdateDate: | 07/14/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GORDON | ||||||||
AuthorizedOfficialFirstName: | JOEL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 4137747900 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 78013 | MA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |   |
ID Information
ID | Type | State | Issuer | Description | G0J14217 | 01 | MA | BCBS | OTHER |