Provider Demographics
NPI:1548616873
Name:GORDON-WOLLIN, EVAN ROSS (DO)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:ROSS
Last Name:GORDON-WOLLIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 69446
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90069-0446
Mailing Address - Country:US
Mailing Address - Phone:310-388-6798
Mailing Address - Fax:
Practice Address - Street 1:1426 MONTANA AVE STE 2
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-1763
Practice Address - Country:US
Practice Address - Phone:310-388-6798
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-05
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A16019207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program