Basic Information
| Provider Information | |||||||||
| NPI: | 1386806248 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | LANCE | ||||||||
| MiddleName: | STEWART | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 68 S SERVICE RD | ||||||||
| Address2: | SUITE 350 | ||||||||
| City: | MELVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117472354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5169453107 | ||||||||
| FaxNumber: | 5169453131 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 HEALTHY WAY | ||||||||
| Address2: | |||||||||
| City: | OCEANSIDE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115721551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166324191 | ||||||||
| FaxNumber: | 5166324195 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2008 | ||||||||
| LastUpdateDate: | 06/06/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP3000X | OS9740 | FL | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology | 207L00000X | OS9740 | FL | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 258288 | NY | N | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 0002109-00 | 05 | FL | MEDICAID | 317169747A | 05 | GA | MEDICAID | A400055931 | 01 | NY | MEDICARE | OTHER |