Provider Demographics
NPI:1154664159
Name:DONALD G GORDON MD LLC
Entity Type:Organization
Organization Name:DONALD G GORDON MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:G
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-270-7592
Mailing Address - Street 1:153 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06470-2791
Mailing Address - Country:US
Mailing Address - Phone:203-270-7592
Mailing Address - Fax:203-426-2175
Practice Address - Street 1:153 S MAIN ST
Practice Address - Street 2:
Practice Address - City:NEWTOWN
Practice Address - State:CT
Practice Address - Zip Code:06470-2791
Practice Address - Country:US
Practice Address - Phone:203-270-7592
Practice Address - Fax:203-426-2175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-28
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT027018207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT060865648OtherPOMCO
CT060865648OtherHORIZON
CT001270180Medicaid
CT78469320OtherCIGNA
CT060865648OtherUNITED HEALTHCARE
CTP419320OtherOXFORD
CT104361700OtherFED OWCPO
CT5521143OtherFIRST HEALTH
CT665648OtherCTCARE
CT5521143OtherCCNNETWORK
CT5521143OtherFIRST HEALTH