Provider Demographics
NPI:1558459008
Name:GORDON, MARC L (MD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:L
Last Name:GORDON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:175 COMMUNITY DR
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-5502
Mailing Address - Country:US
Mailing Address - Phone:516-465-1900
Mailing Address - Fax:516-465-1830
Practice Address - Street 1:611 NORTHERN BLVD
Practice Address - Street 2:SUITE 150
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5207
Practice Address - Country:US
Practice Address - Phone:516-325-7000
Practice Address - Fax:516-325-7001
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY1673602084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01189591Medicaid
NY01189591Medicaid
NY63525BMedicare ID - Type Unspecified