Provider Demographics
NPI:1326033846
Name:GORDON, HERSCHEL W (MD)
Entity Type:Individual
Prefix:
First Name:HERSCHEL
Middle Name:W
Last Name:GORDON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:275 HOSPITAL DR
Mailing Address - Street 2:DEPT OF PATHOLOGY
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-4531
Mailing Address - Country:US
Mailing Address - Phone:707-462-3111
Mailing Address - Fax:707-463-7509
Practice Address - Street 1:275 HOSPITAL DR
Practice Address - Street 2:DEPT OF PATHOLOGY
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-4531
Practice Address - Country:US
Practice Address - Phone:707-462-3111
Practice Address - Fax:707-463-7509
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAC20719207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C207190Medicaid
CABB009ZMedicare PIN
CA00C207190Medicare PIN
CAA31768Medicare UPIN
CA00C207191Medicare PIN