Provider Demographics
NPI:1871623009
Name:GORDON, DANIEL JOSHUA (OD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:JOSHUA
Last Name:GORDON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 SUNSET TER
Mailing Address - Street 2:
Mailing Address - City:TENAFLY
Mailing Address - State:NJ
Mailing Address - Zip Code:07670-1456
Mailing Address - Country:US
Mailing Address - Phone:201-567-6588
Mailing Address - Fax:
Practice Address - Street 1:120 COUNTY RD
Practice Address - Street 2:
Practice Address - City:TENAFLY
Practice Address - State:NJ
Practice Address - Zip Code:07670-1854
Practice Address - Country:US
Practice Address - Phone:201-567-0157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ4673152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
082557Medicare ID - Type Unspecified
NJT84892Medicare UPIN