Provider Demographics
NPI:1245214519
Name:ANDERSON, GORDON (MD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:374 STOCKHOLM ST
Mailing Address - Street 2:DEPARTMENT NEUROSURGERY
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11237-4006
Mailing Address - Country:US
Mailing Address - Phone:718-963-7266
Mailing Address - Fax:718-963-6491
Practice Address - Street 1:374 STOCKHOLM ST
Practice Address - Street 2:DEPARTMENT NEUROSURGERY
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11237-4006
Practice Address - Country:US
Practice Address - Phone:718-963-7266
Practice Address - Fax:718-963-6491
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY233218174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02600035Medicaid
NYI21518Medicare UPIN
NY3102H2Medicare ID - Type Unspecified