1114910007 NPI number — DR. YANA GORDON MD

Table of content: DR. YANA GORDON MD (NPI 1114910007)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114910007 NPI number — DR. YANA GORDON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GORDON
Provider First Name:
YANA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
POLTINNIKOVA
Provider Other First Name:
YANA
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1114910007
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/06/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
118 NORTH BEDFORD ROAD
Provider Second Line Business Mailing Address:
2ND FLOOR
Provider Business Mailing Address City Name:
MOUNT KISCO
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10549-1009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
914-666-8866
Provider Business Mailing Address Fax Number:
914-666-6777

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7600 RIVER RD
Provider Second Line Business Practice Location Address:
PALISADES MEDICAL CENTER
Provider Business Practice Location Address City Name:
NORTH BERGEN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07047-6217
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-854-5172
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/25/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  075537 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0022446 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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