Provider Demographics
NPI:1104038231
Name:GORDON, LESLIE ELLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:ELLEN
Last Name:GORDON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3777 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-1541
Mailing Address - Country:US
Mailing Address - Phone:212-926-0336
Mailing Address - Fax:212-926-0212
Practice Address - Street 1:3777 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-1541
Practice Address - Country:US
Practice Address - Phone:212-926-0336
Practice Address - Fax:212-926-0212
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY243820207W00000X
NJ25MA08313100207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02917788Medicaid
NY02917788Medicaid