Healthcare Provider Details

I. General information

NPI: 1669010914
Provider Name (Legal Business Name): MOBILE WOUND & DIAGNOSTICS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2019
Last Update Date: 12/17/2019
Certification Date: 12/17/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 ROWLAND WAY STE 208
NOVATO CA
94945-5055
US

IV. Provider business mailing address

7 OAKMONT CT
SAN RAFAEL CA
94901-1235
US

V. Phone/Fax

Practice location:
  • Phone: 415-287-0859
  • Fax: 415-202-6228
Mailing address:
  • Phone: 404-275-1396
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code335V00000X
TaxonomyPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: DR. ANTHONY GORDON
Title or Position: PRESIDENT
Credential: MD, WCC
Phone: 415-287-0859