Provider Demographics
NPI:1285740787
Name:GORDON, BARRY MARK (MD)
Entity type:Individual
Prefix:DR
First Name:BARRY
Middle Name:MARK
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 1:212 VAN HOUTEN AVE
Mailing Address - Street 2:APARTMENT 2
Mailing Address - City:PASSAIC
Mailing Address - State:NJ
Mailing Address - Zip Code:07055-4607
Mailing Address - Country:US
Mailing Address - Phone:848-299-3418
Mailing Address - Fax:
Practice Address - Street 1:809 RIVER AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-5286
Practice Address - Country:US
Practice Address - Phone:732-905-9944
Practice Address - Fax:732-444-3118
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY273313207R00000X
NJ25MA07707800207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0849596Medicaid
C29112Medicare UPIN
C29112Medicare UPIN