Healthcare Provider Details

I. General information

NPI: 1811970692
Provider Name (Legal Business Name): LAWRENCE JAY GORDON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2005
Last Update Date: 10/09/2025
Certification Date: 10/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2004 ROUTE 17M
GOSHEN NY
10924-5210
US

IV. Provider business mailing address

2004 ROUTE 17M
GOSHEN NY
10924-5210
US

V. Phone/Fax

Practice location:
  • Phone: 845-294-0661
  • Fax: 845-818-9646
Mailing address:
  • Phone: 845-294-0661
  • Fax: 845-818-9646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number183723
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number183723
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207YX0602X
TaxonomyOtolaryngic Allergy Physician
License Number183723
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: