Provider Demographics
NPI:1881613396
Name:GORDON, VICKI R (MD PHD)
Entity type:Individual
Prefix:DR
First Name:VICKI
Middle Name:R
Last Name:GORDON
Suffix:
Gender:F
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4182 W BROADWAY APT B
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-4092
Mailing Address - Country:US
Mailing Address - Phone:310-956-6842
Mailing Address - Fax:
Practice Address - Street 1:550 E WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:CA
Practice Address - Zip Code:95531-8160
Practice Address - Country:US
Practice Address - Phone:707-496-5465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301083013207R00000X
CA127825207R00000X
CAC127825207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
149719OtherUPIN NUMBER