Provider Demographics
NPI:1225040892
Name:JONATHAN GORDON, MD LLC
Entity Type:Organization
Organization Name:JONATHAN GORDON, MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-790-1776
Mailing Address - Street 1:67 SAND PIT RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-4032
Mailing Address - Country:US
Mailing Address - Phone:203-790-1776
Mailing Address - Fax:203-743-7597
Practice Address - Street 1:67 SAND PIT RD
Practice Address - Street 2:SUITE 200
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-4032
Practice Address - Country:US
Practice Address - Phone:203-790-1776
Practice Address - Fax:203-743-7597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC08007Medicare UPIN