Healthcare Provider Details

I. General information

NPI: 1164450300
Provider Name (Legal Business Name): JORDAN S GITLIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 07/30/2025
Certification Date: 07/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

247 ROUTE 100 SUITE 1002
SOMERS NY
10589-3231
US

IV. Provider business mailing address

1999 MARCUS AVE SUITE M18
NEW HYDE PARK NY
11042-1017
US

V. Phone/Fax

Practice location:
  • Phone: 914-962-8290
  • Fax: 914-962-8851
Mailing address:
  • Phone: 516-466-6953
  • Fax: 516-466-5608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number203315
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License NumberME170154
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number203315
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: