1831158351 NPI number — MR. JOHN DAVID GORDON PAC

Table of content: MR. JOHN DAVID GORDON PAC (NPI 1831158351)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831158351 NPI number — MR. JOHN DAVID GORDON PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GORDON
Provider First Name:
JOHN
Provider Middle Name:
DAVID
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PAC
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:
1831158351
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/16/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
88 E TIOGA AVE STE 102
Provider Second Line Business Mailing Address:
SMITH ALLERGY & ASTHMA OF CNY PLLC
Provider Business Mailing Address City Name:
CORNING
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14830-2858
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
607-684-6115
Provider Business Mailing Address Fax Number:
607-684-6120

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
88 E TIOGA AVE STE 102
Provider Second Line Business Practice Location Address:
88 TIOGA AVENUE, STE 102
Provider Business Practice Location Address City Name:
CORNING
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14830-2858
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
607-684-6115
Provider Business Practice Location Address Fax Number:
607-684-6120
Provider Enumeration Date:
03/22/2006

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: 363A00000X , with the licence number:  MA051642 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 004758 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: J400278137 . This is a "MEDICARE PTAN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: CC9269 . This is a "RR MEDICARE GROUP" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: P00177089 . This is a "RR MEDICARE PIN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: GU040061 . This is a "MEDICARE GROUP" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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