Provider Demographics
NPI:1992879407
Name:GORDON, DAVID W (OD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:W
Last Name:GORDON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:851 N HOLLYWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-2814
Mailing Address - Country:US
Mailing Address - Phone:818-842-2111
Mailing Address - Fax:818-842-4454
Practice Address - Street 1:851 N HOLLYWOOD WAY
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-2814
Practice Address - Country:US
Practice Address - Phone:818-842-2111
Practice Address - Fax:818-842-4454
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6675 TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0066750Medicaid
CACM395AOtherMEDICARE PTAN
CACM395AOtherMEDICARE PTAN
CA6709740001Medicare NSC
CAU37996Medicare UPIN