Healthcare Provider Details

I. General information

NPI: 1265368260
Provider Name (Legal Business Name): AUDREY GORDON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2026
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 BI COUNTY BLVD STE 450
FARMINGDALE NY
11735-3995
US

IV. Provider business mailing address

101 DOGWOOD RD
NORTHPORT NY
11768-1906
US

V. Phone/Fax

Practice location:
  • Phone: 718-264-1640
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: