Provider Demographics
NPI:1598753006
Name:GORDON, EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
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 1:388 HARDSCRABBLE RD
Mailing Address - Street 2:
Mailing Address - City:NORTH SALEM
Mailing Address - State:NY
Mailing Address - Zip Code:10560-1020
Mailing Address - Country:US
Mailing Address - Phone:914-669-5526
Mailing Address - Fax:914-669-6051
Practice Address - Street 1:388 HARDSCRABBLE RD
Practice Address - Street 2:
Practice Address - City:NORTH SALEM
Practice Address - State:NY
Practice Address - Zip Code:10560-1020
Practice Address - Country:US
Practice Address - Phone:914-669-5526
Practice Address - Fax:914-669-6051
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-10
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0861832084P0804X, 2084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC06411Medicare UPIN