Provider Demographics
NPI:1669432258
Name:STREETER, GORDON CHASE (MD)
Entity type:Individual
Prefix:DR
First Name:GORDON
Middle Name:CHASE
Last Name:STREETER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 208237
Mailing Address - Street 2:YALE UNIVERISTY
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06520-8237
Mailing Address - Country:US
Mailing Address - Phone:203-432-0206
Mailing Address - Fax:203-432-0072
Practice Address - Street 1:55 LOCK ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-3603
Practice Address - Country:US
Practice Address - Phone:203-432-0206
Practice Address - Fax:203-432-0072
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT043348208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001433482Medicaid
CT010043348CT01OtherBCBS
CT061511900OtherFED TAX ID