Provider Demographics
NPI:1619996774
Name:GORODOKIN, GARY I (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:I
Last Name:GORODOKIN
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 1:34 KNIGHTS COURT
Mailing Address - Street 2:
Mailing Address - City:UPPER SADDLE RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:07458
Mailing Address - Country:US
Mailing Address - Phone:201-791-7760
Mailing Address - Fax:201-791-7746
Practice Address - Street 1:24-07 A BROADWAY
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410
Practice Address - Country:US
Practice Address - Phone:201-791-7760
Practice Address - Fax:201-791-7746
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA06159800207RG0100X
NY182511207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6878105Medicaid
NY758683OtherEMPIRE
NJ0K7399OtherHEALTH NET
2504592OtherGHI
NYELDERPLANOther183559
NJ3V7781OtherEMPIRE
P698453OtherOXFORD
NJ5596271OtherAETNA
NY758683OtherEMPIRE
NJ6878105Medicaid
NJ800765Medicare PIN