Provider Demographics
NPI:1437245289
Name:GORDON, IAN LOUIS (MDPHD)
Entity Type:Individual
Prefix:DR
First Name:IAN
Middle Name:LOUIS
Last Name:GORDON
Suffix:
Gender:M
Credentials:MDPHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6361 E DEBORAH ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90815-2252
Mailing Address - Country:US
Mailing Address - Phone:562-826-5330
Mailing Address - Fax:562-826-5666
Practice Address - Street 1:5901 E 7TH STREET
Practice Address - Street 2:VAMC LONG BEACH
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90822
Practice Address - Country:US
Practice Address - Phone:562-826-5330
Practice Address - Fax:562-826-5666
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG553502086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA52930Medicare UPIN