Provider Demographics
NPI:1104864024
Name:VAN TASSELL, GORDON E (DO)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:E
Last Name:VAN TASSELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 N LA BREA AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90028-7504
Mailing Address - Country:US
Mailing Address - Phone:323-464-1336
Mailing Address - Fax:323-464-2163
Practice Address - Street 1:1300 N LA BREA AVE
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90028-7504
Practice Address - Country:US
Practice Address - Phone:323-464-1336
Practice Address - Fax:323-464-2163
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6929207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine