Provider Demographics
NPI:1831107077
Name:GORDON, ANTHONY (OD)
Entity type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:
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 1:129 OCONNELL DR
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06118
Mailing Address - Country:US
Mailing Address - Phone:860-870-3800
Mailing Address - Fax:860-870-3802
Practice Address - Street 1:54 HARTFORD TPKE
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:CT
Practice Address - Zip Code:06066-5276
Practice Address - Country:US
Practice Address - Phone:860-646-3400
Practice Address - Fax:860-646-3402
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT002287152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004112843Medicaid
CT410001168Medicare ID - Type Unspecified
CT004112843Medicaid