Provider Demographics
NPI:1033749759
Name:GORDON, ROBERT JOHN (MA)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:JOHN
Last Name:GORDON
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1148 1/2 MENLO AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-3453
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2265 E 103RD ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90002-3132
Practice Address - Country:US
Practice Address - Phone:510-684-4779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-22
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty