Provider Demographics
NPI:1124098959
Name:GORDON, MARK FORREST (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:FORREST
Last Name:GORDON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:972 BRUSH HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-1740
Mailing Address - Country:US
Mailing Address - Phone:516-876-5555
Mailing Address - Fax:516-876-5539
Practice Address - Street 1:865 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5310
Practice Address - Country:US
Practice Address - Phone:516-570-4477
Practice Address - Fax:516-465-1890
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-24
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY1674672084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01155568Medicaid
NY01155568Medicaid
NYE89059Medicare UPIN
NY72494Medicare ID - Type Unspecified