Provider Demographics
NPI:1215242326
Name:GORDON, KRISTIN SHALLCROSS (DO)
Entity type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:SHALLCROSS
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:PO BOX 3055
Mailing Address - Street 2:
Mailing Address - City:SAG HARBOR
Mailing Address - State:NY
Mailing Address - Zip Code:11963-0403
Mailing Address - Country:US
Mailing Address - Phone:631-377-1036
Mailing Address - Fax:
Practice Address - Street 1:600 COMMUNITY DR STE 302
Practice Address - Street 2:
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-3818
Practice Address - Country:US
Practice Address - Phone:516-823-8808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-12
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2782841207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine