Provider Demographics
NPI:1598260523
Name:GORDON, ELLIOTT (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLIOTT
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 1:505 E 70TH ST FL 3
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-4872
Mailing Address - Country:US
Mailing Address - Phone:646-962-3869
Mailing Address - Fax:646-962-0246
Practice Address - Street 1:505 E 70TH ST FL 3
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4872
Practice Address - Country:US
Practice Address - Phone:646-962-3869
Practice Address - Fax:646-962-0246
Is Sole Proprietor?:No
Enumeration Date:2018-03-30
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA010611208000000X
390200000X
NY311651-01208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program