Provider Demographics
NPI:1639457773
Name:GORDON, BRUCE A (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
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 1:8 UPLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-1130
Mailing Address - Country:US
Mailing Address - Phone:415-383-2270
Mailing Address - Fax:
Practice Address - Street 1:8 UPLAND AVE
Practice Address - Street 2:
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941-1130
Practice Address - Country:US
Practice Address - Phone:415-383-2270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-22
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA24767208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice