Provider Demographics
NPI:1699751586
Name:GOURDJI, MAURICE (MD)
Entity type:Individual
Prefix:DR
First Name:MAURICE
Middle Name:
Last Name:GOURDJI
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 1:5525 ETIWANDA AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-3642
Mailing Address - Country:US
Mailing Address - Phone:818-708-6070
Mailing Address - Fax:844-406-5413
Practice Address - Street 1:5525 ETIWANDA AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3647
Practice Address - Country:US
Practice Address - Phone:818-708-6070
Practice Address - Fax:844-406-5413
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG443580207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA100002869OtherRAILROAD MEDICARE
CACR357ZMedicare PIN
CAA92486Medicare UPIN