Provider Demographics
NPI:1972326064
Name:GORDILLO, DEREK
Entity type:Individual
Prefix:MR
First Name:DEREK
Middle Name:
Last Name:GORDILLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 LLEWELLYN AVE.
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08350
Mailing Address - Country:US
Mailing Address - Phone:856-285-9698
Mailing Address - Fax:856-697-0128
Practice Address - Street 1:322 LLEWELLYN AVE.
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:NJ
Practice Address - Zip Code:08350
Practice Address - Country:US
Practice Address - Phone:856-285-9698
Practice Address - Fax:856-697-0128
Is Sole Proprietor?:No
Enumeration Date:2024-11-06
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ31TD00386800156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician