Provider Demographics
NPI:1942275177
Name:SMITH, GORDON W (MD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:W
Last Name:SMITH
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 1:374 GRAND AVE
Mailing Address - Street 2:FAIR HAVEN COMMUNITY HEALTH CENTER
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06513-3733
Mailing Address - Country:US
Mailing Address - Phone:203-777-7411
Mailing Address - Fax:203-777-8506
Practice Address - Street 1:374 GRAND AVE
Practice Address - Street 2:FAIR HAVEN COMMUNITY HEALTH CENTER
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06513-3733
Practice Address - Country:US
Practice Address - Phone:203-777-7411
Practice Address - Fax:203-777-8506
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT015109207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C65100Medicare UPIN