Provider Demographics
NPI:1790121622
Name:LEO A GORDON MD A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:LEO A GORDON MD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEO
Authorized Official - Middle Name:A
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-423-1892
Mailing Address - Street 1:8631 W 3RD ST
Mailing Address - Street 2:SUITE 200E
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5901
Mailing Address - Country:US
Mailing Address - Phone:310-423-1892
Mailing Address - Fax:
Practice Address - Street 1:8631 W 3RD ST
Practice Address - Street 2:SUITE 200E
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5901
Practice Address - Country:US
Practice Address - Phone:310-423-1892
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-19
Last Update Date:2013-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty