Provider Demographics
NPI:1740509165
Name:GORDON, BRIAN PHILLIP GLEN SR
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:PHILLIP GLEN
Last Name:GORDON
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 CAMBRIDGE AVE
Mailing Address - Street 2:29 CAMBRIDGE AVE.
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14215-4001
Mailing Address - Country:US
Mailing Address - Phone:716-931-9899
Mailing Address - Fax:
Practice Address - Street 1:29 CAMBRIDGE AVE
Practice Address - Street 2:29 CAMBRIDGE AVE.
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-4001
Practice Address - Country:US
Practice Address - Phone:716-931-9899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-25
Last Update Date:2010-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY607953011172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver