Provider Demographics
NPI:1124153101
Name:DAVIS, GORDON C (DO)
Entity type:Individual
Prefix:
First Name:GORDON
Middle Name:C
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:10149 WOODHAVEN BLVD
Mailing Address - Street 2:
Mailing Address - City:OZONE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11416-2300
Mailing Address - Country:US
Mailing Address - Phone:718-641-4900
Mailing Address - Fax:718-641-4905
Practice Address - Street 1:9601 JAMAICA AVE LOWR LEVEL
Practice Address - Street 2:
Practice Address - City:WOODHAVEN
Practice Address - State:NY
Practice Address - Zip Code:11421-2295
Practice Address - Country:US
Practice Address - Phone:718-641-4900
Practice Address - Fax:718-641-4905
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2024-04-19
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Provider Licenses
StateLicense IDTaxonomies
NY171745207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYE44184Medicare UPIN
NY14132UMedicare PIN