Provider Demographics
NPI:1912968041
Name:GORDON, ANTHONY K (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:K
Last Name:GORDON
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 1:165 ROWLAND WAY STE 208
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94945-5055
Mailing Address - Country:US
Mailing Address - Phone:415-429-4225
Mailing Address - Fax:415-202-6228
Practice Address - Street 1:165 ROWLAND WAY STE 208
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94945
Practice Address - Country:US
Practice Address - Phone:415-429-4225
Practice Address - Fax:415-202-6228
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA031432174400000X
CAG595222085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000449765AAMedicaid
GA202I300099OtherMEDICARE PROVIDER FOR OMRIB
GA202I300099OtherMEDICARE PROVIDER FOR OMRIB
GAE71966Medicare UPIN