Provider Demographics
NPI:1255409512
Name:GORDON, DOUGLAS MARK (DC)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:MARK
Last Name:GORDON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20700 VENTURA BLVD.
Mailing Address - Street 2:STE. 130
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91364-6277
Mailing Address - Country:US
Mailing Address - Phone:818-345-2660
Mailing Address - Fax:818-206-9471
Practice Address - Street 1:20700 VENTURA BLVD.
Practice Address - Street 2:STE. 130
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91364-6277
Practice Address - Country:US
Practice Address - Phone:818-345-2660
Practice Address - Fax:818-206-9471
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-02
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23821111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABT601BMedicare PIN
CAU64732Medicare UPIN