Provider Demographics
NPI:1134126840
Name:FRIED, GORDON W (DO)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:W
Last Name:FRIED
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 1:200 PLAZA CT
Mailing Address - Street 2:SUITE C
Mailing Address - City:EAST STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18301-8259
Mailing Address - Country:US
Mailing Address - Phone:570-424-5592
Mailing Address - Fax:
Practice Address - Street 1:200 PLAZA CT
Practice Address - Street 2:SUITE C
Practice Address - City:EAST STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18301-8259
Practice Address - Country:US
Practice Address - Phone:570-424-9952
Practice Address - Fax:570-424-0768
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS-007213-E174400000X
PAOS007213E207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012090750005Medicaid
PA0457628OtherAETNA
PA232725862OtherALL OTHER INS
PA075227Other1ST PRIORITY
PA2101332OtherGHI
PA179309K1AMedicare PIN
PA0012090750005Medicaid