Healthcare Provider Details

I. General information

NPI: 1336378561
Provider Name (Legal Business Name): SARI LEE GORDON OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2009
Last Update Date: 10/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1085D NORTHERN BLVD
ROSLYN NY
11576-1632
US

IV. Provider business mailing address

1085D NORTHERN BLVD
ROSLYN NY
11576-1632
US

V. Phone/Fax

Practice location:
  • Phone: 516-365-4066
  • Fax: 516-365-9312
Mailing address:
  • Phone: 516-365-4066
  • Fax: 516-365-9312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUV004015
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberTUV004015
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: