Provider Demographics
NPI:1508023128
Name:GORDON OPTOMETRIC EYECARE LLC
Entity Type:Organization
Organization Name:GORDON OPTOMETRIC EYECARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-646-3400
Mailing Address - Street 1:54 HARTFORD TPKE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-5276
Mailing Address - Country:US
Mailing Address - Phone:860-646-3400
Mailing Address - Fax:860-646-3402
Practice Address - Street 1:54 HARTFORD TPKE
Practice Address - Street 2:SUITE 3
Practice Address - City:VERNON
Practice Address - State:CT
Practice Address - Zip Code:06066-5276
Practice Address - Country:US
Practice Address - Phone:860-646-3400
Practice Address - Fax:860-646-3402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-21
Last Update Date:2008-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC03480Medicare PIN
CT5983000001Medicare NSC