Provider Demographics
NPI:1568455962
Name:GORDON, THEODORE BENNETT (OD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:BENNETT
Last Name:GORDON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:354 SEWALL ST
Mailing Address - Street 2:CENTERGATE COMMONS
Mailing Address - City:LUDLOW
Mailing Address - State:MA
Mailing Address - Zip Code:01056-2711
Mailing Address - Country:US
Mailing Address - Phone:413-583-2260
Mailing Address - Fax:413-583-3957
Practice Address - Street 1:354 SEWALL ST
Practice Address - Street 2:CENTERGATE COMMONS
Practice Address - City:LUDLOW
Practice Address - State:MA
Practice Address - Zip Code:01056-2711
Practice Address - Country:US
Practice Address - Phone:413-583-2260
Practice Address - Fax:413-583-3957
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-31
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2253152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0306452Medicaid
MA0135940001Medicare NSC
MA176858Medicare ID - Type Unspecified
MAT59262Medicare UPIN