Provider Demographics
NPI:1982652939
Name:GORDON, MARK R (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:R
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 1:2870 WHIPTAIL LOOP STE 201
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92010-6766
Mailing Address - Country:US
Mailing Address - Phone:760-331-9771
Mailing Address - Fax:
Practice Address - Street 1:2870 WHIPTAIL LOOP STE 201
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92010-6766
Practice Address - Country:US
Practice Address - Phone:667-243-5377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2025-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2020-0673207RC0000X
WY5823A207RC0000X
SD3929207RC0000X
ORMD220295207RC0000X
CAG-168143207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0008426OtherSD BCBS
25-00667OtherMEDICA SELECTCARE
MN165025OtherUCARE
IA0549402Medicaid
SD3929OtherDAKOTACARE
MN331503700Medicaid
IA33333OtherIA BCBS #
931451030123OtherPREFERRED ONE
10492OtherHEALTHPARTNERS
SD6002892Medicaid
MN101T6GOOtherMN BCBS - PLAN 91057NO
MN346L9GOOtherMN BCBS - PLAN 538R2NO
MN060003507Medicare PIN
SD3929OtherDAKOTACARE
SD0008426OtherSD BCBS
MN331503700Medicaid
IA0549402Medicaid