Provider Demographics
NPI:1154625978
Name:BARRY GORDON D.C., P.A.
Entity type:Organization
Organization Name:BARRY GORDON D.C., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THAD
Authorized Official - Middle Name:BARRY
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:772-567-3334
Mailing Address - Street 1:1986 31ST AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-6628
Mailing Address - Country:US
Mailing Address - Phone:772-567-3334
Mailing Address - Fax:772-567-4523
Practice Address - Street 1:1986 31ST AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-6628
Practice Address - Country:US
Practice Address - Phone:772-567-3334
Practice Address - Fax:772-567-4523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-08
Last Update Date:2011-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH2470111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL89915OtherBLUE CROSS/BLUE SHIELS
FL4400124OtherUNITED HEALTH CARE
T56383Medicare UPIN
FL89915OtherBLUE CROSS/BLUE SHIELS