Provider Demographics
NPI:1801814694
Name:GORDON, LAWRENCE ALVIN (MD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:ALVIN
Last Name:GORDON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 CHESTER DR
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-4904
Mailing Address - Country:US
Mailing Address - Phone:516-829-9142
Mailing Address - Fax:516-829-9142
Practice Address - Street 1:9 CHESTER DR
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-4904
Practice Address - Country:US
Practice Address - Phone:516-829-9142
Practice Address - Fax:516-829-9142
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY094751208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYLG08393210Medicare ID - Type UnspecifiedMEDICARE NUMBER
NYD47824Medicare UPIN