Provider Demographics
NPI:1730536152
Name:GOLD, JON
Entity type:Individual
Prefix:
First Name:JON
Middle Name:
Last Name:GOLD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94 PARK ST
Mailing Address - Street 2:
Mailing Address - City:NEW CANAAN
Mailing Address - State:CT
Mailing Address - Zip Code:06840-5401
Mailing Address - Country:US
Mailing Address - Phone:203-966-6758
Mailing Address - Fax:203-966-8785
Practice Address - Street 1:94 PARK ST
Practice Address - Street 2:
Practice Address - City:NEW CANAAN
Practice Address - State:CT
Practice Address - Zip Code:06840-5401
Practice Address - Country:US
Practice Address - Phone:203-966-6758
Practice Address - Fax:203-966-8785
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-16
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT183500000X183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist