Provider Demographics
NPI:1164506408
Name:GORDON, KAREN (MD)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 PROSPECT PL
Mailing Address - Street 2:SUITE 220
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92118-1978
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:230 PROSPECT PL
Practice Address - Street 2:SUITE 220
Practice Address - City:CORONADO
Practice Address - State:CA
Practice Address - Zip Code:92118-1978
Practice Address - Country:US
Practice Address - Phone:619-435-1138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC41988207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE01727Medicare UPIN