Provider Demographics
NPI:1306987946
Name:GORDON, MARK LORRY (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:LORRY
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 1:16661 VENTURA BLVD
Mailing Address - Street 2:SUITE 716
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-1914
Mailing Address - Country:US
Mailing Address - Phone:818-990-1166
Mailing Address - Fax:
Practice Address - Street 1:16661 VENTURA BLVD
Practice Address - Street 2:SUITE 716
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-1914
Practice Address - Country:US
Practice Address - Phone:818-990-1166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA041223207QG0300X
CAA41223207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Not Answered207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism