Provider Demographics
NPI:1417962093
Name:GORELICK, JUDITH L (MD)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:L
Last Name:GORELICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 BRIDGEPORT AVE
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-3861
Mailing Address - Country:US
Mailing Address - Phone:203-755-6677
Mailing Address - Fax:203-755-7166
Practice Address - Street 1:330 BRIDGEPORT AVE
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484-3861
Practice Address - Country:US
Practice Address - Phone:203-755-6677
Practice Address - Fax:203-755-7166
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT039473207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD400245818Medicare PIN
140000212Medicare ID - Type Unspecified