Provider Demographics
NPI:1265409114
Name:GORNBEIN, GORDON J (MD)
Entity type:Individual
Prefix:DR
First Name:GORDON
Middle Name:J
Last Name:GORNBEIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4484 N PLACITA COAHUILA
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85749-6107
Mailing Address - Country:US
Mailing Address - Phone:503-310-8622
Mailing Address - Fax:
Practice Address - Street 1:4484 N PLACITA COAHUILA
Practice Address - Street 2:SUITE 700
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85749-6107
Practice Address - Country:US
Practice Address - Phone:503-310-8622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2014-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD13026207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR050003045OtherRR MEDICARE
OR022343Medicaid
WA1048024Medicaid
OR050003045OtherRR MEDICARE
OR00WCJPPLMedicare ID - Type Unspecified