Provider Demographics
NPI:1295770907
Name:GORDON, MICHELLE ELAINE (DO)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:ELAINE
Last Name:GORDON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 PEEKSKILL HOLLOW RD # 97
Mailing Address - Street 2:
Mailing Address - City:PUTNAM VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:10579-0097
Mailing Address - Country:US
Mailing Address - Phone:845-526-2080
Mailing Address - Fax:845-526-2082
Practice Address - Street 1:11 PEEKSKILL HOLLOW RD # 97
Practice Address - Street 2:
Practice Address - City:PUTNAM VALLEY
Practice Address - State:NY
Practice Address - Zip Code:10579-3200
Practice Address - Country:US
Practice Address - Phone:845-526-2080
Practice Address - Fax:845-526-2082
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-17
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY236050-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY4879H1OtherMEDICARE PETAN
NY2682460Medicaid
NY2682460Medicaid