Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN0400X | Neurology | 000976 | CT |
NPI | 1184845356 |
---|---|
Provider Name | Mr. Mitchell Mason Gordon |
First Address | Norwalk, CT 06850-1416 |
Second Address | Norwalk, CT 06850-1416 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/05/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
050000976CT02 | ANTHEM BLUE CROSS & BLUE (01) | CT |
0976 | (02) | CT |
720384 | CTCARE (01) | CT |