Provider Demographics
NPI:1184845356
Name:GORDON, MITCHELL MASON (DC)
Entity Type:Individual
Prefix:MR
First Name:MITCHELL
Middle Name:MASON
Last Name:GORDON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 NEW CANAAN AVE
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06850-1416
Mailing Address - Country:US
Mailing Address - Phone:203-846-0421
Mailing Address - Fax:203-849-9022
Practice Address - Street 1:233 NEW CANAAN AVE
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06850-1416
Practice Address - Country:US
Practice Address - Phone:203-846-0421
Practice Address - Fax:203-849-9022
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000976111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN0400XChiropractic ProvidersChiropractorNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT050000976CT02OtherANTHEM BLUE CROSS & BLUE
CT720384OtherCTCARE
CT050000976CT02OtherANTHEM BLUE CROSS & BLUE