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General NPI Number Information
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NPI Number | 1689844276
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Entity Type | Organization
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Legal Business Name | THEODORE B GORDON OD
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Dates
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Enumeration Date | 03/10/2008
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Last Update Date | 03/20/2008
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Provider Practice Location Address
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Address Line | 354 SEWALL ST
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City | LUDLOW
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State | MA
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Zip | 01056-2711
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Country | US
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Telephone | 413-583-2260
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Fax | 413-583-3957
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Provider Business Mailing Address
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Address Line | 354 SEWALL ST
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City | LUDLOW
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State | MA
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Zip | 01056-2711
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Country | US
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Telephone | 413-583-2260
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Fax | 413-583-3957
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Authorized Official
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Title or Position | OWNER /OPTOMETRIST
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Name | DR. THEODORE B GORDON
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Credential | OD
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Telephone | 413-583-2260
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number | 2253
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License Number State | MA
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