Provider Demographics
NPI:1255487518
Name:MATHESON, GORDON OMAR (MD, PHD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:OMAR
Last Name:MATHESON
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:341 GALVEZ ST
Mailing Address - Street 2:ARRILLAGA MC 6150
Mailing Address - City:STANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:94305-6106
Mailing Address - Country:US
Mailing Address - Phone:650-723-2257
Mailing Address - Fax:650-725-2607
Practice Address - Street 1:341 GALVEZ ST
Practice Address - Street 2:ARRILLAGA MC 6150
Practice Address - City:STANFORD
Practice Address - State:CA
Practice Address - Zip Code:94305-6106
Practice Address - Country:US
Practice Address - Phone:650-723-2257
Practice Address - Fax:650-725-2607
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAC43343204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF94522Medicare UPIN