Provider Demographics
NPI:1659406361
Name:GORDON, MAUREEN FULCHIERO (MD)
Entity Type:Individual
Prefix:DR
First Name:MAUREEN
Middle Name:FULCHIERO
Last Name:GORDON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11980 SAN VICENTE BLVD
Mailing Address - Street 2:#704
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-5012
Mailing Address - Country:US
Mailing Address - Phone:310-826-2664
Mailing Address - Fax:310-395-2046
Practice Address - Street 1:11980 SAN VICENTE BLVD
Practice Address - Street 2:#704
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-5012
Practice Address - Country:US
Practice Address - Phone:310-826-2664
Practice Address - Fax:310-395-2046
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA249792084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Not Answered2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry