Healthcare Provider Details

I. General information

NPI: 1912968041
Provider Name (Legal Business Name): ANTHONY K GORDON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 05/08/2020
Certification Date: 05/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 ROWLAND WAY STE 208
NOVATO CA
94945
US

IV. Provider business mailing address

165 ROWLAND WAY STE 208
NOVATO CA
94945-5055
US

V. Phone/Fax

Practice location:
  • Phone: 415-429-4225
  • Fax: 415-202-6228
Mailing address:
  • Phone: 415-429-4225
  • Fax: 415-202-6228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number031432
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberG59522
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: