Provider Demographics
NPI:1720189509
Name:SNYDER, G GORDON III (MD)
Entity Type:Individual
Prefix:DR
First Name:G
Middle Name:GORDON
Last Name:SNYDER
Suffix:III
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 1:701 COTTAGE GROVE RD
Mailing Address - Street 2:A-230
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002-3080
Mailing Address - Country:US
Mailing Address - Phone:860-242-5274
Mailing Address - Fax:860-242-3643
Practice Address - Street 1:701 COTTAGE GROVE RD
Practice Address - Street 2:A-230
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002-3080
Practice Address - Country:US
Practice Address - Phone:860-242-5274
Practice Address - Fax:860-242-3643
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT15262207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001152628Medicaid
040000101OtherMEDICARE PTAN
CTB39455Medicare UPIN
CT001152628Medicaid