Provider Demographics
NPI:1649243890
Name:GORDON, CHARLES FOX III (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:FOX
Last Name:GORDON
Suffix:III
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 1:9 OLD PLANK RD STE 100
Mailing Address - Street 2:
Mailing Address - City:CLIFTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12065-3107
Mailing Address - Country:US
Mailing Address - Phone:518-371-0777
Mailing Address - Fax:518-371-0366
Practice Address - Street 1:9 OLD PLANK ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:CLIFTON PARK
Practice Address - State:NY
Practice Address - Zip Code:12065-3107
Practice Address - Country:US
Practice Address - Phone:518-371-0777
Practice Address - Fax:518-371-0366
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1889491207LP2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1339826Medicaid
NY000405090003OtherBSNENY PIN - SPECIALIST
NY01339826Medicaid
NYP00044697Medicare PIN
NY01339826Medicaid