Provider Demographics
NPI:1811970692
Name:GORDON, LAWRENCE JAY (MD)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:JAY
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 1:2004 ROUTE 17M
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:NY
Mailing Address - Zip Code:10924-5210
Mailing Address - Country:US
Mailing Address - Phone:845-294-0661
Mailing Address - Fax:845-818-9646
Practice Address - Street 1:2004 ROUTE 17M
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:NY
Practice Address - Zip Code:10924-5210
Practice Address - Country:US
Practice Address - Phone:845-294-0661
Practice Address - Fax:845-818-9646
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-25
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY183723207YX0007X, 207Y00000X, 207YX0602X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
No207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic Allergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY116999OtherWELLCARE
0182804OtherGHI
NY040007473OtherRAILROAD MEDICARE
3824829OtherOXFORD
NY384148POtherHIP
NY10035906OtherCDPHP
NY4572033OtherAETNA
8M7342OtherBCBS NY
10000172090012OtherAFFINITY HEALTH PLAN
NY120076OtherGHI HMO
NY01515700Medicaid
NY047123OtherMVP
ZE3167OtherHEALTHNET OF NORTHEAST
ZE3167OtherHEALTHNET OF NORTHEAST