Provider Demographics
NPI:1407825516
Name:GORDON, WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:
Last Name:GORDON
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 1:5 E. 98TH STREET
Mailing Address - Street 2:6TH FLOOR BOX 1240 B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029
Mailing Address - Country:US
Mailing Address - Phone:212-659-8353
Mailing Address - Fax:212-348-5901
Practice Address - Street 1:5 E. 98TH STREET
Practice Address - Street 2:6TH FLOOR BOX 1240 B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029
Practice Address - Country:US
Practice Address - Phone:212-659-9363
Practice Address - Fax:212-348-5901
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004201-1225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYR50750Medicare UPIN
NYV05672Medicare ID - Type Unspecified