Active NPI
Mark Howard Gordon, DDS
- General Practice Dentistry
- Valley Stream, NY
National Provider Identifier
1396734331
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Dentistry
- License
- 036092
- Practice address
- 15 Fletcher Ave
Valley Stream, NY 11580-4000 - Phone
- (516) 561-1577
- Fax
- (516) 561-1577
- NPI assigned
- Oct 20, 2005
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | 036092 | NY | Primary |
Addresses
Primary practice location
15 Fletcher Ave
Valley Stream, NY 11580-4000
Mailing address
15 Fletcher Ave
Valley Stream, NY 11580-4000
Phone (516) 561-1577
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 00717506 | Medicaid | NY |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 036092 | NY | MD | General Practice Dentistry |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1129766400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1396734331",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "15 FLETCHER AVE",
"city": "VALLEY STREAM",
"state": "NY",
"postal_code": "115804000",
"telephone_number": "516-561-1577",
"fax_number": "516-561-1577"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "15 FLETCHER AVE",
"city": "VALLEY STREAM",
"state": "NY",
"postal_code": "115804000",
"telephone_number": "516-561-1577",
"fax_number": "516-561-1577"
}
],
"practiceLocations": [],
"basic": {
"last_name": "GORDON",
"first_name": "MARK",
"middle_name": "HOWARD",
"name_prefix": "Dr.",
"credential": "DDS",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2005-10-20",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "NY",
"license": "036092",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "00717506",
"state": "NY"
}
],
"endpoints": [],
"other_names": []
}Other providers in Valley Stream, NY
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.