Provider Demographics
NPI:1174620579
Name:GORDON, JEFFREY B (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:B
Last Name:GORDON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 PORTLAND AVE
Mailing Address - Street 2:STE 400
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621-3038
Mailing Address - Country:US
Mailing Address - Phone:585-922-4200
Mailing Address - Fax:
Practice Address - Street 1:1415 PORTLAND AVE
Practice Address - Street 2:STE 400
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-3038
Practice Address - Country:US
Practice Address - Phone:585-922-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY151996207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00958443Medicaid
NYD02302Medicare UPIN
NYRA9080Medicare PIN