Provider Demographics
NPI:1689844276
Name:THEODORE B GORDON OD
Entity Type:Organization
Organization Name:THEODORE B GORDON OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER /OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:B
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:413-583-2260
Mailing Address - Street 1:354 SEWALL ST
Mailing Address - Street 2:
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:
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-10
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2253332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0135940001Medicare NSC