Provider Demographics
NPI:1306874151
Name:GORDON, RONALD (MD)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:
Last Name:GORDON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 OLD COURTHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-1115
Mailing Address - Country:US
Mailing Address - Phone:516-365-7800
Mailing Address - Fax:
Practice Address - Street 1:425 OLD COURTHOUSE RD
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-1115
Practice Address - Country:US
Practice Address - Phone:516-365-7800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1373162084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00617749Medicaid
NY00617749Medicaid
NY53A681Medicare ID - Type Unspecified