Healthcare Provider Details

I. General information

NPI: 1063515443
Provider Name (Legal Business Name): BARRY J GORDON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 07/02/2024
Certification Date: 07/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 LEWIS AVE STE 221
MERIDEN CT
06451-2121
US

IV. Provider business mailing address

455 LEWIS AVE STE 221
MERIDEN CT
06451-2121
US

V. Phone/Fax

Practice location:
  • Phone: 203-694-8550
  • Fax: 203-694-7698
Mailing address:
  • Phone: 203-694-8550
  • Fax: 203-694-7698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0008X
TaxonomyNeuromuscular Medicine (Psychiatry & Neurology) Physician
License Number000511
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number000511
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: