Provider Demographics
NPI:1033158670
Name:PHILLIPS, GORDON D (MD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:D
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10069
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92423-0069
Mailing Address - Country:US
Mailing Address - Phone:909-793-3311
Mailing Address - Fax:909-793-2916
Practice Address - Street 1:2 W FERN AVE
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-5916
Practice Address - Country:US
Practice Address - Phone:909-793-3311
Practice Address - Fax:909-793-2916
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2013-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG54853207P00000X
CAG588532083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G548530Medicaid
CA00G548530Medicaid