Healthcare Provider Details

I. General information

NPI: 1295770907
Provider Name (Legal Business Name): MICHELLE ELAINE GORDON D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 12/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 PEEKSKILL HOLLOW RD # 97
PUTNAM VALLEY NY
10579-3200
US

IV. Provider business mailing address

11 PEEKSKILL HOLLOW RD # 97
PUTNAM VALLEY NY
10579-0097
US

V. Phone/Fax

Practice location:
  • Phone: 845-526-2080
  • Fax: 845-526-2082
Mailing address:
  • Phone: 845-526-2080
  • Fax: 845-526-2082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number236050-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: