Provider Demographics
NPI:1124028030
Name:PRICE, GORDON A (OD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:A
Last Name:PRICE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 FRONT ST
Mailing Address - Street 2:UNIT 81
Mailing Address - City:SCITUATE
Mailing Address - State:MA
Mailing Address - Zip Code:02066-1315
Mailing Address - Country:US
Mailing Address - Phone:781-545-0792
Mailing Address - Fax:781-545-4323
Practice Address - Street 1:85 FRONT ST
Practice Address - Street 2:UNIT 81
Practice Address - City:SCITUATE
Practice Address - State:MA
Practice Address - Zip Code:02066-1315
Practice Address - Country:US
Practice Address - Phone:781-545-0792
Practice Address - Fax:781-545-4323
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2009-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2268152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0313165Medicaid
0751510001Medicare NSC
MAW1511301Medicare PIN
MA0313165Medicaid