Provider Demographics
NPI:1780678433
Name:H.W. GORDON, M.D., MEDICAL CORPORATION
Entity Type:Organization
Organization Name:H.W. GORDON, M.D., MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HERSCHEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-462-3111
Mailing Address - Street 1:275 HOSPITAL DR
Mailing Address - Street 2:DEPT OF PATHOLOGY
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-4531
Mailing Address - Country:US
Mailing Address - Phone:707-462-3111
Mailing Address - Fax:707-463-7509
Practice Address - Street 1:275 HOSPITAL DR
Practice Address - Street 2:DEPT OF PATHOLOGY
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-4531
Practice Address - Country:US
Practice Address - Phone:707-462-3111
Practice Address - Fax:707-463-7509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-08
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C207190Medicaid
CA00C207191Medicaid
CA00C207191Medicare PIN
CA00C207190Medicaid
CA00C207190Medicare PIN