Provider Demographics
NPI:1508906090
Name:GORDON, MARTIN A (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:A
Last Name:GORDON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11999 SAN VICENTE BLVD
Mailing Address - Street 2:#440
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-5131
Mailing Address - Country:US
Mailing Address - Phone:310-471-5852
Mailing Address - Fax:310-471-3958
Practice Address - Street 1:1250 16TH ST
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-1249
Practice Address - Country:US
Practice Address - Phone:310-471-5852
Practice Address - Fax:310-471-3958
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2009-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC38040207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C38400Medicaid
CA00C38400Medicaid