Provider Demographics
NPI:1386860575
Name:GORDON, MARVIN ISAAC (MD)
Entity Type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:ISAAC
Last Name:GORDON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:M.
Other - Middle Name:ISAAC
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:163 N FORMOSA AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-2817
Mailing Address - Country:US
Mailing Address - Phone:310-622-3600
Mailing Address - Fax:
Practice Address - Street 1:3300 E SOUTH ST STE 207
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90805-4549
Practice Address - Country:US
Practice Address - Phone:562-602-5503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA83747207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG17435Medicare UPIN