1619996774 NPI number — GARY I GORODOKIN MD

Table of content: GARY I GORODOKIN MD (NPI 1619996774)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619996774 NPI number — GARY I GORODOKIN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GORODOKIN
Provider First Name:
GARY
Provider Middle Name:
I
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1619996774
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/15/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
34 KNIGHTS COURT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
UPPER SADDLE RIVER
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07458
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-791-7760
Provider Business Mailing Address Fax Number:
201-791-7746

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
24-07 A BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIR LAWN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07410
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-791-7760
Provider Business Practice Location Address Fax Number:
201-791-7746
Provider Enumeration Date:
07/19/2006

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: 207RG0100X , with the licence number:  MA06159800 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RG0100X , with the licence number: 182511 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 6878105 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 758683 . This is a "EMPIRE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 0K7399 . This is a "HEALTH NET" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 2504592 . This is a "GHI" identifier . This identifiers is of the category "OTHER".
  • Identifier: ELDERPLAN . This is a "183559" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 3V7781 . This is a "EMPIRE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: P698453 . This is a "OXFORD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5596271 . This is a "AETNA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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