1114974342 NPI number — MARK FORREST GORDON, MD, PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114974342 NPI number — MARK FORREST GORDON, MD, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARK FORREST GORDON, MD, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114974342
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
70 FIR DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11576-2406
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-484-0882
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3003 NEW HYDE PARK RD
Provider Second Line Business Practice Location Address:
STE 312
Provider Business Practice Location Address City Name:
NEW HYDE PARK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11042-1214
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-488-3200
Provider Business Practice Location Address Fax Number:
516-488-3266
Provider Enumeration Date:
05/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GORDON
Authorized Official First Name:
MARK
Authorized Official Middle Name:
FORREST
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
516-488-3200

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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