Provider Demographics
NPI:1770553505
Name:GORDON, JOEL PETER (MD)
Entity type:Individual
Prefix:DR
First Name:JOEL
Middle Name:PETER
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 1:453 AUDUBON RD
Mailing Address - Street 2:
Mailing Address - City:LEEDS
Mailing Address - State:MA
Mailing Address - Zip Code:01053-9771
Mailing Address - Country:US
Mailing Address - Phone:413-585-9157
Mailing Address - Fax:
Practice Address - Street 1:3455 MAIN ST
Practice Address - Street 2:SUITE 5
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107-1142
Practice Address - Country:US
Practice Address - Phone:413-733-9600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-24
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA78013207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA12706OtherHEALTH NEW ENGLAND
MA758399OtherTUFTS HEALTH PLANS
MA758399OtherTUFTS INSURANCE
MAJ14217OtherBLUE CROSS BLUE SHIELD
MA043238282OtherAETNA
MA4500254OtherAETNA
MA747282OtherCONNECTICARE
MA3147062OtherCIGNA
MA043238282OtherAETNA
MA747282OtherCONNECTICARE
MA758399OtherTUFTS INSURANCE