Provider Demographics
NPI:1063515443
Name:GORDON, BARRY J (DO)
Entity type:Individual
Prefix:
First Name:BARRY
Middle Name:J
Last Name:GORDON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 LEWIS AVE STE 221
Mailing Address - Street 2:
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06451-2121
Mailing Address - Country:US
Mailing Address - Phone:203-694-8550
Mailing Address - Fax:203-694-7698
Practice Address - Street 1:455 LEWIS AVE STE 221
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06451-2121
Practice Address - Country:US
Practice Address - Phone:203-694-8550
Practice Address - Fax:203-694-7698
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0005112084N0008X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0008XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeuromuscular Medicine
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001005116Medicaid
CT130000528Medicare ID - Type Unspecified
CT001005116Medicaid