Provider Demographics
NPI:1003979154
Name:CHARLES R. GORDON,M.D. PC
Entity Type:Organization
Organization Name:CHARLES R. GORDON,M.D. PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-769-2668
Mailing Address - Street 1:262 CENTRAL PARK W
Mailing Address - Street 2:SUITE 1E
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-3512
Mailing Address - Country:US
Mailing Address - Phone:212-769-2668
Mailing Address - Fax:212-362-8738
Practice Address - Street 1:262 CENTRAL PARK W
Practice Address - Street 2:SUITE 1E
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-3512
Practice Address - Country:US
Practice Address - Phone:212-769-2668
Practice Address - Fax:212-362-8738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY140363208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA60639Medicare UPIN