Provider Demographics
NPI:1053330563
Name:HEISS, GORDON LEIGH (DO)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:LEIGH
Last Name:HEISS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 LYON PL
Mailing Address - Street 2:
Mailing Address - City:OGDENSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13669-2590
Mailing Address - Country:US
Mailing Address - Phone:315-713-6700
Mailing Address - Fax:
Practice Address - Street 1:3 LYON PL
Practice Address - Street 2:
Practice Address - City:OGDENSBURG
Practice Address - State:NY
Practice Address - Zip Code:13669-2590
Practice Address - Country:US
Practice Address - Phone:315-713-6700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY199696207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01600059Medicaid
NYG16572Medicare UPIN