Provider Demographics
NPI:1760424758
Name:GORDON, BRUCE LEWIS (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:LEWIS
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 1:1 BYRAM BROOK PL
Mailing Address - Street 2:
Mailing Address - City:ARMONK
Mailing Address - State:NY
Mailing Address - Zip Code:10504-2316
Mailing Address - Country:US
Mailing Address - Phone:914-820-0000
Mailing Address - Fax:914-949-4505
Practice Address - Street 1:1 BYRAM BROOK PL
Practice Address - Street 2:
Practice Address - City:ARMONK
Practice Address - State:NY
Practice Address - Zip Code:10504-2316
Practice Address - Country:US
Practice Address - Phone:914-820-0000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY111088207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00198861Medicaid
NY00198861Medicaid
NY511371Medicare ID - Type Unspecified