Provider Demographics
NPI:1073998670
Name:GORDON, RENAULDO
Entity Type:Individual
Prefix:DR
First Name:RENAULDO
Middle Name:
Last Name:GORDON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1503 SAINT JOHNS PL
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11213-3910
Mailing Address - Country:US
Mailing Address - Phone:646-673-1317
Mailing Address - Fax:
Practice Address - Street 1:1503 SAINT JOHNS PL
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11213-3910
Practice Address - Country:US
Practice Address - Phone:646-673-1317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-23
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYXXXXXXXX207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine