Provider Demographics
NPI:1124013248
Name:GORDON, MARSHA
Entity Type:Individual
Prefix:DR
First Name:MARSHA
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-5754
Mailing Address - Country:US
Mailing Address - Phone:212-475-5324
Mailing Address - Fax:212-987-1197
Practice Address - Street 1:5 E 98TH ST
Practice Address - Street 2:5TH FLOOR BOX 1048
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6501
Practice Address - Country:US
Practice Address - Phone:212-241-8234
Practice Address - Fax:211-987-1197
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY163800207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA60947Medicare UPIN
NY17E241Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER