Healthcare Provider Details

I. General information

NPI: 1689607194
Provider Name (Legal Business Name): MARTIN LAWRENCE GORDON MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 04/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 S FLOWER ST
LOS ANGELES CA
90007-2629
US

IV. Provider business mailing address

210 N TUSTIN AVE
SANTA ANA CA
92705-3807
US

V. Phone/Fax

Practice location:
  • Phone: 213-742-1000
  • Fax:
Mailing address:
  • Phone: 800-883-7243
  • Fax: 714-647-1245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA25996
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberA25996
License Number StateCA

VIII. Authorized Official

Name: DR. MARTIN L GORDON
Title or Position: SOLE OWNER
Credential: M.D.
Phone: 800-883-7243