Provider Demographics
NPI:1053534925
Name:GORDON, EARL MARK (MD)
Entity type:Individual
Prefix:DR
First Name:EARL
Middle Name:MARK
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 1:2001 SANTA MONICA BLVD
Mailing Address - Street 2:SUITE # 765 - W
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2102
Mailing Address - Country:US
Mailing Address - Phone:310-453-4599
Mailing Address - Fax:310-453-6620
Practice Address - Street 1:2021 SANTA MONICA BLVD STE 421E
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2144
Practice Address - Country:US
Practice Address - Phone:310-453-4599
Practice Address - Fax:310-453-6620
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG 35140207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ 73491 ZMedicaid
CAG 35140OtherCALIFORNIA MED. LICENSE
CAW1311Medicare ID - Type Unspecified
A 46230Medicare UPIN