Provider Demographics
NPI:1821392796
Name:ALAN N. GORDON, OD, INC.
Entity type:Organization
Organization Name:ALAN N. GORDON, OD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:N
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:219-924-8012
Mailing Address - Street 1:1650 45TH AVE
Mailing Address - Street 2:SUITE I
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-3962
Mailing Address - Country:US
Mailing Address - Phone:219-924-8012
Mailing Address - Fax:
Practice Address - Street 1:1650 45TH AVE
Practice Address - Street 2:SUITE I
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-3962
Practice Address - Country:US
Practice Address - Phone:219-924-8012
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-06
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001595152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100212460Medicaid