Provider Demographics
NPI:1588626964
Name:GORDON, DAVID JEFFERY (DPM)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:JEFFERY
Last Name:GORDON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 BEACH 20TH ST
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-3618
Mailing Address - Country:US
Mailing Address - Phone:718-327-3968
Mailing Address - Fax:
Practice Address - Street 1:224 BEACH 20TH ST
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-3618
Practice Address - Country:US
Practice Address - Phone:718-327-3968
Practice Address - Fax:718-228-4815
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-03
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN006085213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02778045Medicaid
NYA400011124Medicare PIN
NY02778045Medicaid
NYPJ8011Medicare PIN
NYG300012224Medicare PIN
NY5932950001Medicare NSC