Provider Demographics
NPI:1104837657
Name:GORDON, KENNETH L (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:L
Last Name:GORDON
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 1:2080 CENTURY PARK EAST, #800
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90067-2011
Mailing Address - Country:US
Mailing Address - Phone:310-277-2727
Mailing Address - Fax:310-553-2135
Practice Address - Street 1:2080 CENTURY PARK EAST, #800
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90067-2011
Practice Address - Country:US
Practice Address - Phone:310-277-2727
Practice Address - Fax:310-553-2135
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC36598207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA10019OtherK.L. GORDON M.D. MES #
CACA0783OtherEYE MED GROUP PROVIDER #
CAGR0071730Medicaid
CA00C365980OtherK.L. GORDON BL/SHLD #
CA33106001OtherK.L. GORDON -DAVIS VISION
CA891978OtherK.L. GORDON -BLOCK VISION
CAP-11051496OtherK.L. GORDON MULTI-PLAN #
CA26923OtherSPECTERA GROUP PROVIDER #
CAWC36598CMedicare PIN
CAWC36598BMedicare PIN
CA10019OtherK.L. GORDON M.D. MES #
CAP-11051496OtherK.L. GORDON MULTI-PLAN #