Healthcare Provider Details

I. General information

NPI: 1770847600
Provider Name (Legal Business Name): MERNA GORDON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2012
Last Update Date: 06/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

770 GROTE STREET
BRONX NY
10460
US

IV. Provider business mailing address

770 GROTE STREET PS 188/34X
BRONZ NY
10460
US

V. Phone/Fax

Practice location:
  • Phone: 718-561-2052
  • Fax: 718-561-2683
Mailing address:
  • Phone: 718-561-2052
  • Fax: 718-561-2683

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4672541
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: