Provider Demographics
NPI:1891066221
Name:MARVIN ISAAC GORDON MD A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:MARVIN ISAAC GORDON MD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:ISAAC
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-622-3600
Mailing Address - Street 1:163 N FORMOSA AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-2817
Mailing Address - Country:US
Mailing Address - Phone:310-622-3600
Mailing Address - Fax:
Practice Address - Street 1:3300 E SOUTH ST STE 207
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90805-4549
Practice Address - Country:US
Practice Address - Phone:562-602-5503
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-17
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA83747207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty