Provider Demographics
NPI:1144242645
Name:GORDON, RICHARD KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:KENNETH
Last Name:GORDON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:RICHARD
Other - Middle Name:KENNETH
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:8700 RESEDA BLVD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91324-4041
Mailing Address - Country:US
Mailing Address - Phone:818-772-7090
Mailing Address - Fax:
Practice Address - Street 1:8700 RESEDA BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91324-4041
Practice Address - Country:US
Practice Address - Phone:818-772-7090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG56286174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G562860Medicaid
CA00G562860Medicaid
CAG56286Medicare ID - Type UnspecifiedMEDICARE RPROVIDER NUMBER